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Credit Application
Company Information
Date
MM slash DD slash YYYY
Company Name
DBA
Shipping Address
Street Address
City
State
ZIP
Billing Address
Street Address
City
State
ZIP
Phone
Fax
Federal ID #
Ownership Type
State Reseller #
Date of Incorporation
Dun & Bradstreet
State of Incorporation
# of Employees
Business Type
VAR
Reseller
Manufacturer
Distributor
Other
Credit Type
Net30
Net15
Credit Card
COD
PrePay
Other
Amount Requested
Business Contacts
CEO/President Name
CEO/President Phone
CEO/President Email
CFO/Treasurer Name
CFO/Treasurer Phone
CFO/Treasurer Email
Accounts Payable Name
Accounts Payable Phone
Accounts Payable Email
Bank Information
Institution Name
Address
City, St, Zip
Phone
Contact Name
Account #
Account Type
Checking
Savings
Trade Information
Company Name
Company Name
Address
Address
City, St, Zip
City, St, Zip
Phone
Phone
Fax
Fax
Contact Name
Contact Name
Terms\Credit Line
Terms\Credit Line
Company Name
Company Name
Address
Address
City, St, Zip
City, St, Zip
Phone
Phone
Fax
Fax
Contact Name
Contact Name
Terms\Credit Line
Terms\Credit Line
Customer's authorized representative signing this agreement hereby represents and warrants that the information provided in this application and in any and all additional documents, financial statements or other information furnished by Customer to Synergy Micro Solutions, LLC (hereafter Synergy) is true and correct in all material respects and contains all information necessary so that this application is not materially misleading. This agreement shall become effective upon acceptance by Synergy. Customer and anyone signing on their behalf, acknowledge that the information contained in this credit application is true and accurate. According to Synergy's invoice(s), customer agrees to make payment in full to Synergy. Should Customer default in any payment(s) due to Synergy, Synergy shall have the right, without notice to Customer or Guarantor, to declare all invoice amounts to Synergy due immediately. Customer also agrees to pay Synergy, as interest, an amount equal to 1.25% per month, or the maximum provided by law (whichever is less) for invoice amounts that are past due. Should any action commence to collect any amounts owed by customer to Synergy, Customer and/or Guarantor, consent to jurisdiction and a location in Orange County, CA Superior Courts, and agree to pay reasonable attorney fees, court and other expenses incurred by Synergy, including any and all related fees and costs of appeals, whether or not a lawsuit is filed. Customer acknowledges that the information provided is accurate and being submitted on their own behalf, and for the sole purpose of purchasing computer products for their customers and/or themselves. Customer hereby grants Synergy a security interest in any goods purchased from Synergy by Customer acknowledged on this application. In addition, the customer's accounts receivable and proceeds from accounts receivable attributable to Customer's resale of such goods shall be the obligation of Customer to Synergy for any obligation of payment. The person authorized by this customer to sign this agreement represents that Synergy will be promptly notified in writing in the event that any of the information provided to Synergy in connection with the application changes. The authorized person signing this agreement represents and warrants that the customer named in this application is bound by its terms.
Print Name
Signature of Authorized Representative
Are you currently working with a Synergy Representative?
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