On-Line Credit Application




Company name 
Address      
P.O. Box     
City         
State        
Zip Code     

Telephone    
Fax          

Principal/President  
Vice President       
Years in business    
Resale certificate # 
P.O.'s Required      
Have you ever declared bankruptcy? 
Date of Discharge    

Duns #   
S.S. #

If in business less than 3 years, or the business is a propretorship or Partnership, the following information must be completed.

Owner 1:


Owner name 
Address    
City       
State      
Zip        
Phone

Owner 2:


Owner name 
Address    
City       
State      
Zip        
Phone

Principal Bank:


Name        
Branch      
Account No. 
Contact     
Address     
City        
State       
Zip         
Telephone   
Fax

Credit References:


Name      
Address   
City      
State     
Zip       
Telephone 
Fax       
Contact   


Name      
Address   
City      
State     
Zip       
Telephone 
Fax       
Contact   


Name      
Address   
City      
State     
Zip       
Telephone 
Fax       
Contact   


Credit line requested 

Who is authorized to purchase goods?

Name  Title 
Name  Title 
Name  Title

In consideration of the extension of credit by Dyna-Lift, Inc., we agree to the following terms and conditions:

Terms: Net 10 days from the date of invoice on all parts and service invoices, Equipment sales net due on delivery.

Costs: Applicant further agrees to pay all collection costs, including attorney's fees and court costs necessary to take legal action to collect past due accounts.

Authorization: Applicant agrees to release banking, trade references and credit information to Dyna-Lift, Inc. for the purpose of making credit decisions.

We agree


By      
Title   
Date