Business Credit Reports

Company Information

Company Name

DBA

Address

City

State/Province

Zip/Postal Code

Country

Phone

DUNS #

Tax Identification #

Website

Billing Address

Billing City

Billing State/Province

Billing Zip/Postal Code

Billing Country

Preferred method of communication for invoices and payment request (Email/Mail/Phone)

If Email or Phone, please list the email address or phone number

Contact Information

First Name

Last Name

Title

Phone

Sales Contact with Troxler

Bank References

Bank

Account #

Contact

Address

City

State

Zip

Phone

Supplier Reference #1

Company

Contact

Phone

Fax

Supplier Reference #2

Company

Contact

Phone

Fax

Supplier Reference #3

Company

Contact

Phone

Fax

Tax Exemption

Are you Tax Exempt? (Yes/No)

If Yes, exemption #

If Yes, what state

Request

Requested Amount

Comments (400 characters max)

Supporting Documentation

Supporting Documents can be your own credit reference sheet and your tax exemption certificate which is required if you claim tax exemption.

Click the Browse / Choose Files button above to select the files you want to send. Then click the Upload button.
Please keep individual file sizes to 4MB or less.

Uploaded Documents

Terms

Payment terms are Net 30 from the invoice date unless otherwise agreed. Troxler Electronic Laboratories reserves the right to charge a service charge of 1.5% per month, but not in excess of any lawful rate, if an invoice is not paid in full by the due date. Past due invoices will be referred to an attorney for collection 90 days after the invoice date. All orders are subject to Troxler's terms and conditions for sale or service.

I accept the above terms.

Please Sign Below

Using a touchpad or mouse, please sign in the area below. When finished signing, please click the Save Signature.

Submit the Request

By clicking 'Submit', I/We authorize Troxler Electronic Laboratories or its agent to obtain a credit report for the purpose of establishing, maintaining or enforcing a credit relationship. Upon approval of credit, I/We agree to pay our account according to the terms granted and I/We acknowledge that I/We have read and fully understand this application.

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