NCO Credit Application Form


Social Security or Federal Identification Number (circle one)

Funding/Sponsoring Agency/Individual  as it appears with credit reporting agencies.

Name ______________________________________

Address_____________________________________________________________________

City_____________________State ___ Zip Code_____________

Phone Number (����� )___________Fax Number (���� )____________

Accounts Payable contact _____________________________________Ext._______

Type of Organization

Corporation

Partnership

Proprietor

Owners, Partners, or Corporate Officers

Name_________________________Title______________________Phone Number_______________ Name_________________________Title______________________Phone Number_______________ Name_________________________Title______________________Phone Number_______________

Line of business _____________________________________________

Year Established _______________Student Enrollment ___________________

Does your organization use purchase orders? ��� Yes�� No

��

Tax Status (Tax will be charged unless exemption certificate is provided.) 

Taxable

Tax-exempt#____________

 

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 (���� )____________

  

Credit References- Net 30 references (please do not include credit cards)

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 (����� )___________��

 

Ship to Information

Individual or Organization Name ______________________________________________________

Street Address_____________________________________________________________________

City_____________________State ___ Zip Code_____________

Phone Number (����� )___________Fax 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 Early Childhood Manufacturers' Direct 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 Early Childhood Manufacturers' Direct of any changes in financial and ownership status.Applicant shall reimburse Early Childhood Manufacturers' Direct 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_________________