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Business Name
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Phone
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Purchase Order
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Business Name
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City, State, Zip
Phone
Contact/Title
  
Customer Notes:
Product Details:
Qty Item No. Description Unit Price Total Price

Fax Orders to: 1-650-654-4366   Merchandise Total
Phone Orders: 1-650-654-4300
Sales Tax
www.ErgoDirect.com
510 Elm Street Shipping
San Carlos
CA 94070
  Order Total

Credit Application
First time users must include credit application with order
Billing & Shipping Information
 
Official Company Name
Bill to Ship to (if different)
Main Phone

Main Fax

A/P Fax
   
Business Information
 
Check One Below:
Corporation Partnership Proprietorshiip Subsidiary of or Division of
Years in Operation   Type of Business
Net Worth   Sales Per Year
D & B #:      
President / CEO   Treasurer/Controller
VP / Finance   A/P Manager
 
Bank Information
         
Bank   Contact Name
Account No   Phone
Complete Address
 
Trade References
         
Reference 1  

Contact
Phone No  

Fax No
 
Reference 2  

Contact
Phone No  

Fax No
 
Reference 3   Contact
Phone No   Fax No
 
Customer's Authorization to Release Bank and Trade Information
Attention Bank and Trade References: Please provide information on all accounts listed as well as any loan information. You will be serving our interest best if you provide the information over the phone. Thank you.
 
I/We hereby authorize you to whom this application is made, or your agents, to investigate my/our credit worthiness and will provide financial statements, tax returns etc., as you deem necessary.
 
Prepared by   Title   Date
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