CREDIT APPLICATION

Credit Line Requested:

Choose an amount $1 - $15K $16 - $25K $26 - $50K $51 - $100K Over $100K

Type of Company:

Choose a type Private Public

AlphaCard Account #:

Company Name:

Doing Business As:

Company Website:

A/P Invoice Contact:

A/P Invoice Phone:

Fax:

A/P Invoice Email:

Dun & Bradstreet #:

Parent Dun & Bradstreet #:

Registered Company Address:

Previous Address:

City:

State/Province:

ZIP/Postal Code:

Stock Symbol:

Agreement

• I / We agree to make all payments within our 30 day terms with AlphaCard.
• I hereby release any and all credit or financial information to AlphaCard or its assignees.

Name:

Title:

Date:

ALL REQUIRED FIELDS (MARKED BY ) SHOULD BE COMPLETE. IF YOU HAVE ANY QUESTIONS, PLEASE CALL 800-717-8080.
Please submit any purchase orders to sales@alphacard.com or to your sales representative.