Credit Application
Toll Free: (855) 735-PTOL
Phone: (207) 897-5558
Fax:
(207) 897-1117
[email protected]
175 Park Street • Livermore Falls, Maine 04254
Name:
_________________________________________________________________________________________________
Address:
_______________________________________________________
Phone: (____) _____ - _________
_______________________________________________________
Fax: (____) _____ - _________
_______________________________________________________
Social Security or Tax ID number:
_____________________________________
Type of Business: _______________________________
Years in Business:
_____________
Name of Owner: ______________________________
Is Your Business:
□
Amount of Credit Desired
$__________________
Person to contact regarding orders:
__________________________________________________________________________
Corporation
□
Proprietorship
□ Partnership
Person to contact regarding payment __________________________________________________________________________
Pay By Credit Card: Do you wish to enroll in PTOL’s automatic credit card draft?
Type of Card:
□ Visa □ MC
□
YES
□ NO
Card Number: ______________________________________________________
Name on Card:____________________________________________ Exp. Date _____/_______/_____________
Credit Reference
Bank Name:______________________________________________
Contact Person: _________________________________
Address: _______________________________________________________________________________________________________
Trade References (Please list three)
Name:______________________________________________________________ Account #:
Address:____________________________________________________________ Phone:
Contact:____________________________________________________________ Fax:
Name:______________________________________________________________ Account #:
Address:____________________________________________________________ Phone:
Contact:____________________________________________________________ Fax:
Name:______________________________________________________________ Account #:
Address:____________________________________________________________ Phone:
Contact:____________________________________________________________ Fax:
As an authorized agent of my company, I am applying for credit with Pine Tree Orthotic Lab, LLC (PTOL). I hereby authorize PTOL and its agents to use the above
information to determine its credit worthiness. I hereby certify that this information is correct to my knowledge, and I realize that initial orders may be shipped C.O.D.
Pending your credit approval. The company above agrees to abide by terms and conditions of sale and will pay all legal fees associated with collection should this account
become delinquent.
Signature of Authorized Agent:_______________________________________________________________________________ Date ______/_______/_________