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_____________________________________________________
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______________________ 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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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?___________________________________ TRADE REFERENCES: - Give Only Names Of Those You Buy From On Open Account Name____________________________________________Contact_____________________________________ Address__________________________________City_______________________State______Zip_____________ Account
Number______________________________Phone_____________________Fax____________________ Name____________________________________________Contact_____________________________________ Address__________________________________City_______________________State______Zip_____________ Account
Number______________________________Phone_____________________Fax____________________ Name____________________________________________Contact_____________________________________ Address__________________________________City_______________________State______Zip_____________ Account
Number______________________________Phone_____________________Fax____________________ Name____________________________________________Contact_____________________________________ Address__________________________________City_______________________State______Zip_____________ Account
Number______________________________Phone_____________________Fax____________________ Bank__________________________________________Account Number_________________________________ Address_______________________________City_________________________State______Zip______________ 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: Phase-A-Matic, Inc., 39360 3rd St. E., Ste. 301, Palmdale, Ca. 93550-3255 |