Company Name:

Address:

City, State, Zip:

Phone, Fax, Amount Request:

    US$

Number of Employees:

Years in Business:

Federal Tax I.D. #

Resale ID #

Principle Function of Business:

Contact Name for Accounts Payable:

Telephone Number for Accounts Payable:

Principal Owner/Officer Name:

Home Address:

City, State, Zip:

Social Security Number:

Principal Owner/Officer Name:

Home Address:

City, State, Zip:

Social Security Number:

Bank Name:

Bank Address:

Bank Phone, Fax:

Account Number:

Bank Name:

Bank Address:

Bank Phone, Fax:

Account Number:

*Regretfully, American Sunrex cannot accept trade references from Tech Data or Ingram Micro as they decline to provide credit references for their clients.

Company Name:

Address:

Phone and Fax:

Account Number:

Company Name:

Address:

Phone and Fax:

Account Number:

Company Name:

Address:

Phone and Fax:

Account Number:

Company Name:

Address:

Phone and Fax:

Account Number:

Authorized Officer:

Date: