Customer Credit Application
Credit & Account Setup
Don't fill this out:
$ Credit Limit Requested
(Required)
Application Date
Type of Customer
(i.e., ALC, Distributor, OEM, End User)
Company Information
Registered Company Name
Trading Name
Division or Subsidiary of
Street Address
City
State/Province
Zip/Postal Code
Country
Main Phone
Main Fax
VAT#/Exemption #
(US - Please attach exemption certificate)
Company Registration Number
Billing Address
(Street or P.O. Box)
City
State/Province
Zip/Postal Code
Country
Shipping Address
(No PO Box Numbers)
City
State/Province
Zip/Postal Code
Country
Direct Phone
Direct Fax
Finance Manager
Email Address
Finance Phone
Finance Fax
If ALC: Licensing Specialist Name
Email Address
Licensing Specialist Address
Licensing Specialist Phone
Business Profile
Organized as:
Corporation
Sole Proprietorship
Partnership
LLC
Date Business was Established
Under the Laws of
(State/Province/Country)
We are engaged in the business of:
Number of Employees
Business Building Is:
Owned
Rented
Owners / Officers
Name
Title
Address
Own
Rent
Home Phone #
Has Applicant or any of its Owners, Principles, Officers or Directors ever filed a voluntary petition in bankruptcy, been adjusted bankrupt, or made an assignment for the benefit of creditors?
Yes
No
Are delinquent taxes owed by Applicant to any taxing authority?
Yes
No
Has a tax lien or civil suit been filed against Applicant or any of its Owners, Principles, Officers, or Directors within the past six years?
Yes
No
Is Applicant or any of its Owners, Principles, Partners, Officers, or Directors a guarantor or endorser of debts or notes owned by others?
Yes
No
Bank References
Bank Name
Branch
Street Address
City
State/Province
Zip/Postal Code
Country
Direct Phone
Direct Fax
Account Officer
Checking Account Number
Savings Account Number
Credit Line Amount with Bank
Loan Amount
Secured
Yes
No
Secured By
Submit Application
Your information is securely transmitted to Luma Optics.
