page 1 (to print, highlight entire application and print the selection)

CREDIT APPLICATION

INNOVAT CORPORATION

“Welding & Industrial P.C. Board Repair”

For All Postal: PO Box 1187 * Marion, VA 24354

For UPS, Fed-Ex, DHL, etc.: 896 Adwolfe Rd. * Marion, VA 24354

BILLING INFORMATION

Company Name

AP Contact Name

Address

City, ST, Zip

Phone:

Fax:

E-mail:

You may provide your UPS / Fed-Ex Shipper # :

For Marketing purposes, how did you hear about us?

SHIP TO INFORMATION

Contact Name

Company Name

Address

City, ST, Zip

Phone:

Fax:

E-mail:

GENERAL COMPANY INFORMATION

Federal Tax ID Number:                                  Dunn & Bradstreet Number:

**Please enclose a W-9 Form (signature required)**

**Virginia companies that are tax exempt must submit a copy of exemption.**

Principle Officer:                                                         Title:

Legal Structure (check all that apply)             Corporation                    LLC                                Sole Proprietor                       Partnership                     LLP                                Non-Profit

In Business Since:                     Type of Business:                                                    ** (determines if discount is available)

Has the company or any of its Principals ever declared Bankruptcy?             Yes      No

If Yes, please explain: _____________________________________________________ ______________________________________________________________________

You may choose the following account options: please circle the following:

            *C.O.D (add $19.00 + S&H)        *VISA         *MasterCard                

or  

*Open Account (3 trade references required for an open account; see page 2)

** If you choose Visa or Mastercard, you must call us with your credit card number.

 page2

THIS PAGE IS ONLY REQUIRED IF YOUR ARE WANTING AN OPEN ACCOUNT 

BANK REFERENCES

Bank Name (#1)

Bank Address

City, ST, Zip

Bank Contact                                               Bank Phone:

Bank Name (#2)

Bank Address

City, ST, Zip

Bank Contact                                                Bank Phone

TRADE REFERENCES

(Phone #’s & Fax #’s required)

1. Company

Address

City, ST, Zip

Contact

Phone:

Fax:

E-mail:

2.  Company

Address

City, ST, Zip

Contact

Phone:

Fax:

E-mail:

3.  Company

Address

City, ST, Zip

Contact

Phone:

Fax:

E-mail:

 

SIGNATURE & AUTHORIZATION

The signature below represents and warrants that (a) the party signing below is an authorized representative of the company; and (b) that the information provided herein is a complete and accurate representation of the company’s financial situation as of the date hereof.  Any misrepresentations or fraudulent information provided will be a basis for default under this agreement. By signing this form, I expressly authorize Innovat Corporation to contact the above references to determine credit worthiness.

Signature:                                                                 Date:

Print Name:                                             Business Title: