On Account Application

Billing Information

Individual (first, middle & last) or Organization Name______________________________________
Bill to Address__________________________________________________
City_____________________ State ___ Zip Code_____________
Phone Number (   )___________ Fax Number (   )____________
Social Security or Federal Identification Number ______________

Ship to Information (if applicable)

Individual or Organization Name ________________________________________________
Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Phone Number (   )___________ Fax Number (   )____________

Billing Address History (include five years if applicable)

Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Phone Number (   )___________ Fax Number (   )____________

Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Phone Number (   )___________ Fax Number (   )____________

Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Phone Number (   )___________ Fax Number (   )____________

Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Phone Number (   )___________ Fax Number (   )____________

Organization/Business Account Information Only Owners, Partners, or Corporate Officers

Name_________________________Title______________________ Phone Number_______________
Name_________________________Title______________________ Phone Number_______________
Name_________________________Title______________________ Phone Number_______________

Contact for Bookkeeping/Accounts Payable____________________
Phone Number________

Type of Organization � Corporation � Partnership � Proprietor

Line of business ______________________________________________________

Year Established_______________Enrollment___________________

Funding/Sponsoring Agency (if applicable)________________________________________

Does your organization use purchase orders? � Yes � No

Tax Status (Tax will be charged unless exemption certificate is provided.) � Taxable � Tax-exempt #____________

Credit References

Name__________________________________________________________________________
Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Account Number___________________
Phone Number (   )___________

Name__________________________________________________________________________
Street Address____________________________________________________
City_____________________ State ___ Zip Code_____________
Account Number ___________________
Phone Number (   )___________

Financial Institution References

Bank Name _____________________________________________________________________
Street Address____________________________________________________
City_____________________ State _____ Zip Code_____________
Account Number ___________________
Phone Number (   )___________

Bank Name _____________________________________________________________________
Street Address____________________________________________________
City_____________________ State _____ Zip Code_____________
Account Number ___________________
Phone Number (   )___________

Terms and Credit Purchase Agreement

The undersigned certifies that all the information on this form is correct and that the firm is not insolvent and the company is in good standing. The applicant authorizes ECMD to obtain necessary credit information at any time from any source including a credit bureau report and agrees to pay for purchases according to the terms of Net 30. Applicant warrants that all information is accurate as of date signed and will notify in writing to ECMD of any changes in financial and ownership status. Applicant shall reimburse ECMD for all expenses incurred resulting from all costs of collection, including attorney fees and legal expenses of any indebtedness owed on past due balances.

Signature___________________________________________________Date_________________

For Questions, Please call
(800) 482-5846 Phone
(831) 333-2592 Fax
Attn: Accounting Credit Dept.
P.O. Box 7636
Spreckles, CA 93962-7636
or
email openacct@ecmdstore.com
Thank you!

7.25.01