35 Green Mountain Drive • South Burlington • VT • 05403 • USA
ph 802-863-0085 • fax 802-419-4986 • www.instrumart.com
Instrumart is a registered trade name of Total Temperature Instrumentation, Inc. ("TTI").
CREDIT APPLICATION
PLEASE COMPLETE, SIGN AND FAX BACK TO (802) 419-4986 OR EMAIL TO
CREDIT@INSTRUMART.COM WITH YOUR PURCHASE ORDER
(1) COMPANY INFORMATION
Legal Name of Company
Incorporation Partnership
Proprietorship Sub-Chapter S
Years in Business
All DBAs
Federal Tax ID# Est. Annual Purchases
Shipping Address
City, State, Zip Code
(2) BILLING INFORMATION (required – PLEASE FILL THIS SECTION OUT)
Billing Address
City, State, Zip Code
Accounts Payable Contact Name Phone # Fax # E-Mail Address
Purchasing Contact Name Phone # Fax # E-Mail Address
Resale Certificate or Direct Pay Permit Number (attach copy).
Tax Exempt?
yes no
D&B Number
Please choose how you prefer invoices to be sent: e-mailed to: ______________________ faxed to: _________________
(3) BANK REFERENCES
Name of Bank
Street Address City, State, Zip Code
Account No.
Name of Contact Phone # Fax #
(4) MAJOR TRADE REFERENCES (must relate to credit applicant)
Name of Company Contact Person Fax # or Email address
1.
2.
3.
(5) AUTHORIZATION (required)
The undersigned, as an officer of the above Company 1) Warrants that all information provided in this application is true and correct and will be used in connection
with the extension of credit. 2) Authorizes and releases all banks, financial institutions and other persons listed on this application to furnish the financial and credit
information requested. 3) Agrees that the above Company shall pay all costs of enforcing the Companies obligations under this agreement to Instrumart including
legal fees and court costs accrued should the account become severely delinquent and 3
rd
party collection services are required . By acceptance of Instrumart goods,
the Company acknowledges that the ABOVE terms and conditions of Instrumart shall govern and shall constitute the entire agreement between the Company and
Instrumart, notwithstanding any different purchase orders terms provided by the Company. The laws of the state of Vermont shall govern any transactions
between the Company and Instrumart. Payment is due by ACH or check 30 days from the date of invoice. Interest shall accrue and be payable on outstanding
balances at 1.5% per month.
Signed
Title Date
PLEASE NOTE THAT ACCOUNTS THAT ARE GRANTED CREDIT TERMS ARE EXPECTED TO PAY
BY CHECK OR ACH. WE DO NOT ACCEPT CREDIT CARD PAYMENTS FOR TERM ACCOUNTS.
