PHASE-A-MATIC, INC.

APPLICATION FOR PHASE-A-MATIC DISTRIBUTORSHIP

Name Of Company__________________________________E-mail_____________________________

Billing Address______________________________________________Phone_____________________

City__________________________________State_________Zip_________Fax___________________

Shipping Address_____________________________________________Phone____________________

City__________________________________State_________Zip__________Fax__________________

Type Of Business____________________________________________Number Of Employees_______

Resale Number _______________________________________________________________________

Name Of Parent Company (If Subsidiary)__________________________________________________

President, Proprietor Or Partner's Name___________________________________________________

Accounts Payable Contact_______________________________________________________________

At Present Location Since (Date)_______________________Year Established_____________________

Is Business Incorporated?___________     If So, Under What State?____________________________

What Types Of Equipment Do You Sell? List Brand Names, Sizes, Or Models:

____________________________________________________________________________________

____________________________________________________________________________________

Have You Sold Phase Converters Before?    Yes______       No______

If Yes, What Brands?___________________________________________________________________

How Long?_________________________       Approx. Annual Purchases?________________________

Type Of Billing Requested:

______ Net 30 (Credit Application Required),      ______COD,       ______Payment In Advance

Are Purchase Order Numbers Required?  Yes_____       No_____

Name Of Authorized Purchasing Agent_____________________________________________________

 

______________________________________                  ______________________
Signature / Title                                                       Date

Print this page and fax the completed form to Phase-A-Matic at 1-661-947-8764, or mail to us at: Phase-A-Matic, Inc., 39360 3rd St. E., Ste. 301, Palmdale, Ca. 93550-3255
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PHASE-A-MATIC, INC.
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CREDIT APPLICATION

Firm Name________________________________________Phone__________________Fax__________________

Billing Address_____________________________City_______________________State________Zip__________

Delivery Address___________________________City_______________________State________Zip__________

Type Of Business_________________________________Resale Number_________________________________

Name Of Parent Company If Subsidiary____________________________________________________________

President, Proprietor Or Partner's Name____________________________________________________________

Home Address & Phone_________________________________________________________________________

Accounts Payables Supervisor_________________________________________Phone______________________

At Present Location Since________________________________________Year Established__________________

Is Business Incorporated?________  If So, Under Laws Of What State?___________________________________
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TRADE REFERENCES: - Give Only Names Of Those You Buy From On Open Account

Name____________________________________________Contact_____________________________________

Address__________________________________City_______________________State______Zip_____________

Account Number______________________________Phone_____________________Fax____________________
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Name____________________________________________Contact_____________________________________

Address__________________________________City_______________________State______Zip_____________

Account Number______________________________Phone_____________________Fax____________________
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Name____________________________________________Contact_____________________________________

Address__________________________________City_______________________State______Zip_____________

Account Number______________________________Phone_____________________Fax____________________
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Name____________________________________________Contact_____________________________________

Address__________________________________City_______________________State______Zip_____________

Account Number______________________________Phone_____________________Fax____________________
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Bank__________________________________________Account Number_________________________________

Address_______________________________City_________________________State______Zip______________
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Amount Of Credit Applied For______________________________

Our Terms Are NET-30. Payment Is Due Not Later Than 30 Days After Invoice Date.

Name_______________________________________________Title_____________________________________

Signature____________________________________________Date____________________________________

FOR OFFICE USE ONLY:

Credit Approved By:                                      Limit:                              Date:

Print this page and fax the completed form to Phase-A-Matic at 1-661-947-8764, or mail to us at:
Phase-A-Matic, Inc., 39360 3rd St. E., Ste. 301, Palmdale, Ca. 93550-3255