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Credit Application


Once all fields on this form have been filled in, please submit the form using the button at the bottom of this page. After submitting your application, print it out, sign the credit terms agreement page, and fax the agreement page to 541-485-5712.

COMPANY INFORMATION
Company Name:    
Main Phone: Main Fax:
Mailing Address: Shipping Address:
Contact Name : Contact Email:
Form of Organization: Corporation Partnership Sole Proprietorship
Other (please describe)
Date Business Established: Type of Business:
President's Name: Controller's Name:
Controller's Phone/Ext: Controller's Email:
Accounts Payable Contact: Credit Requested:
Invoices currently paid in days.
       
FOUR TRADE REFERENCES with phone numbers and addresses
Company Name: Company Name:
Phone: Phone:
Fax: Fax:
Address: Address:
Contact Name: Contact Name:
Contact Email: Contact Email:
Company Name: Company Name:
Phone: Phone:
Fax: Fax:
Address: Address:
Contact Name: Contact Name:
Contact Email: Contact Email:
       
BANK REFERENCE
Bank Name    
Phone: Fax:
Address: Contact Name:
Contact Email:
Account Number: Type of Acct.:


 
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  Small Form Factor Special Interest Group (SFF-SIG) Restriction of Hazardous Substances (RoHS)
VersaLogic Corp. (541) 485-8575
4211 W. 11th Ave. • Eugene, OR 97402

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