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eToner.com  CREDIT APPLICATION                   
Print and fax to: 800 289 8083 or mail to eToner.com, PO Box 1349, New Milford CT 06776 OR click here to apply Online
  

 Business Name
 Address
 City / State  Zip Code 
 Contact person (Purchasing) 
 Phone    Fax
 Contact person (Accounts Payable) 
 Phone  Fax
 Federal tax ID or Social Security number. 
 Type of business  No. of employees
 Date business established
 Types of products you will purchase
 Are you a (circle one):
 CORPORATION          PARTNERSHIP            SOLE PROPRIETORSHIP
 State of Incorporation ______________
 Names, titles, and addresses of your three chief corporate officers (or partners)


 Are you sales tax exempt (circle one)?         Yes        No
 Names of authorized purchasers


 Purchase order required (circle one)?         Yes        No
TRADE REFERENCES  Name                                                                    
 REFERENCE #1  Address
 Phone                                                                Email
 REFERENCE #2  Name           
 Address
 Phone                                                                Email
 REFERENCE #3  Name
 Address
 Phone                                                                Email
BANK REFERENCES  Account #
 BANK #1 Contact Person                                                     Phone
Name of Bank                                                       Address:
 
I represent that the above information is true and is given to induce  to extend credit to the applicant. My company and I authorize  to make such credit investigation as  sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to  any and all information concerning the financial and credit history of my company and myself.
I have read the terms and conditions stated below and agree to all of these terms and conditions.
Printed name:               Authorized signature:
Title: Date: