Business Credit Reports

Company Information

Company Name

DBA

Type of Business (Individual, Partnership, Corporation, LLC, Other)

If "Other", please list

Authorized to Request Credit

Title

Year Established

Industry Of Business

Estimated Annual Purchase

Address

City

State/Province

Zip/Postal Code

Country

Phone

Fax

Billing Street Address

Billing City, State, Zip

Federal EIN or TIN

D&B DUNS #

Sales Tax Status (Taxable, Exempt)

Vacuworx Sales Rep

PO Required for Rental/Lease/Purchase?

Certificate of Insurance Issued (Yes, No)

Have you ever filed bankruptcy? (Yes, No)

If so, please provide the year

Contact Information

First Name

Last Name

Title

Phone

Fax

Accounts Payable Contact Information

Accounts Payable Contact Name

Accounts Payable Phone

Accounts Payable Email

Email address for invoices

Credit Reference #1

Company

Contact

Phone

Fax

Address

Account #

Credit Reference #2

Company

Contact

Phone

Fax

Address

Account #

Credit Reference #3

Company

Contact

Phone

Fax

Address

Account #

Authorized to Purchase #1

Name

Phone

Authorized to Purchase #2

Name

Phone

Authorized to Purchase #3

Name

Phone

Bank Reference #1

Bank Name

Address

City, State, Zip

Contact

Phone

Fax

Account #

Bank Reference #2

Bank Name

Address

City, State, Zip

Contact

Phone

Fax

Account #

Owner/Guarantor #1

Name

Business Title

Address

City, State, Zip

Phone

Owner/Guarantor #2

Name

Business Title

Address

City, State, Zip

Phone

Request

Requested Credit Limit

Comments (400 characters max)

Supporting Documentation

If Tax Exempt, please attach your tax exempt certificate.

Click the Browse / Choose Files button above to select the files you want to send. Then click the Upload button.
Please keep individual file sizes to 4MB or less.

Uploaded Documents

Terms

All information in this credit application is correct, and I understand that payment terms are net 30 days. I understand and am authorized to guarantee payment on behalf of Guarantors to Vacuworx Global, LLC for all debts
including service charges, attorney fees, and court costs incurred by this company through credit extended by Vacuworx
Global, LLC for the purchase and/or rental/lease of goods and merchandise.

I understand and hereby authorize the release of banking and trade information from the references submitted in this application to Vacuworx Global, LLC for the purpose of applying for credit.

I accept the above terms.

Please Sign Below

Using a touchpad or mouse, please sign in the area below. When finished signing, please click the Save Signature.

Submit the Request

By clicking 'Submit', I/We authorize Vacuworx Global LLC or its agent to obtain a credit report for the purpose of establishing, maintaining or enforcing a credit relationship. Upon approval of credit, I/We agree to pay our account according to the terms granted and I/We acknowledge that I/We have read and fully understand this application.

Your session is about to expire