Application for Credit

Bill to: Ship to:
Exact Name Exact Name
Address Address
City City
State State
Zip Code Zip Code
Telephone Telephone
General Business Information
Type of Business
DBA
Individual
Partnership
Corporate
Tax I.D. or Social Security number
Guarantor's Drivers License
Years in Business
Year of Incorporation
State of Incorporation
Officer Name Officer Title
Officer Name Officer Title
Officer Name Officer Title
Accounts Payable Contact
Name
Phone
Fax
Email
Do you require a purchase order? Yes
No
Are you resale tax exempt?
Download Resale Tax Exempt Form
Fax form to 281-259-1662. 		Yes
No
Bank Reference
Bank Name City
Handling Officer State Zip
Business References (Please list a minimum of 4)
Company Name City State Account/Cust # Phone Fax
Your Name
Date
Are you sales tax exempt?
Download Sales Tax Exempt Form
Fax form to 281-259-1662. 		Yes
No
Do you agree to the terms of the ITGLM Purchase Agreement?
Click here to Read Agreement
Yes
No

* = Required fields

Private Krankenversicherung (PKV)