Pricing /Credit Application
 
  Company Name:  
     
  Billing  
  Address:  
  City:  
  State:  
  Zip:  
       
  Delivery  
  Address:  
  City:  
  State:  
  Zip:  
       
  Phone # :  
  Fax # :  
       
  Nature of Business:  
  Date Established:  
  Purchasing Agent :  
  Acc. Payable Contact:  
       
  Other Address Please fill out the following if payment remitted form
a location other than the billing address above
  Address:  
  City:  
  State:  
  Zip:  
  Phone # :  
  Fax # :  
 
       
  Bank Reference :  
  Banking Officer :  
  Account Number:  
  Phone Number:  
       
  Business References: please use references who will give information by phone  
  1. Business   Phone #:  
  2. Business   Phone #:  
  3.Business   Phone #:  
       
  Purch. Order Required: Yes No  
  Tax Exempt : Yes No  
  Tax Number :  
  Reason for Exemption:    
     
  Name of Officer:  
    I hereby certify the information I have given above is correct
to the best of my knowledge and authorize Perimeter Systems
to use this information to process my credit application:
Yes No