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(954) 616-8787
contactus@allmediasupply.com
800 International Pkwy,
Sunrise, FL 33025
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Credit Account Application Form
1
COMPANY ADDRESS & CONTACT INFORMATION
Legal Business Name:
DBA / Trade Name:
Street Address:
City:
State:
Zip/Postcode:
Primary Contact Name:
Title:
Telephone:
Fax:
Mobile:
Email Address:
2
COMPANY DETAILS
Federal Tax ID #:
State Sales Tax ID #:
Total Projected annual turnover with AMS $
Amount of Credit Requested $:
Type of Business
Length of Time in Business:
3
ACCOUNTS PAYABLE (A/P)
A/P Contact Name:
A/P Contact Phone:
A/P Contact Fax:
A/P Contact Email Address:
Statement Email address if different from the above:
4
REGISTERED OFFICE
Registered Agent:
Street Address:
City:
State:
Zip/Postcode:
Company Registered Number:
Telephone:
Fax:
Email:
5
BANKING INFORMATION
Bank Name:
Street Address:
City:
State:
Zip/Postcode:
Officer Contact Name:
Telephone:
Fax:
Email:
Account Number:
Type of Account:
6
ALL PARTNERS, DIRECTORS, PROPRIETORS & OFFICERS
Person
1
Name:
Position:
Street Address:
City:
State:
Zip/Postcode:
Home Phone:
SSN:
Person
2
Name:
Position:
Street Address:
City:
State:
Zip/Postcode:
Home Phone:
SSN:
7
TRADE REFERENCES (All 3 references must be completed)
Reference
1
Company Name:
Account:
Contact Name:
Street Address:
City:
State:
Zip/Postcode:
Telephone:
Fax:
Email:
Reference
2
Company Name:
Account:
Contact Name:
Street Address:
City:
State:
Zip/Postcode:
Telephone:
Fax:
Email:
Reference
3
Company Name:
Account:
Contact Name:
Street Address:
City:
State:
Zip/Postcode:
Telephone:
Fax:
Email:
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