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Credit Application
Corporate Info
Legal Business Name:
required
Legal business name is required.
Date Established:
required
Date established is required.
Phone Number:
required
Phone number is required.
Trade Name:
if different from legal name / dba
Fax Number:
Address:
required
Address is required.
City:
required
City is required.
State:
required
State is required.
Zip:
required
ZipCode is required.
Salesperson:
Adam Worsnop
Amir Golparvar
Brian Corn
Dan Webber
Dave Grieve
David Lebov
Eric Aske
Gary Hoehn
Jeff Graczyk
Jeff Pritchett
Jon Breen
Luigi Giovanetti
Pamela Kantor
Pete Donohue
Accounts Payable Contact
Contact Name:
required
Contact name is required.
Contact Phone:
required
Contact phone is required.
Contact Email:
required
Contact email is required.
Digital Invoice Delivery Email:
required
Digital invoice delivery email is required.
Corporate Profile
Tax ID / Fed ID:
D&B Number:
Stock Symbol:
Annual Sales Volume:
required
Annual sales volume is required.
Bank / Trade Reference
Must have account number under same dba and/or legal name
Bank Name:
required
Bank name is required.
Checking Account #:
Savings Account #:
Loan Account #:
Contact Name:
required
Contact name is required.
Contact Phone:
required
Bank contact phone is required.
Contact Email:
required
Bank contact email is required.
Trade References
Please provide at least 3 trade references
You may also attach/upload reference files:
Name:
Terms:
Address:
Phone:
Add a trade reference
Credit Request
Account Terms Requested:
required
Account terms requested is required.
Requested Credit Limit:
required
Tax-Exempt Organizations
Optional
Please attach/upload any exemption certificate(s):
Certify Information / Financial Release
I certify that the above information is true and correct. Furthermore, I authorize financial institutions to release necessary information to Integrated IT Solutions LLC in order to verify the information contained herein.