Polydyne Business Account Application

"*" indicates required fields

COMPANY DATA

Company Name*

Employer Identification Number*

Years in Business*

Business Type*

Corporation

Limited Liability Corporation

Partnership

Sole-Proprietor

Other

Dun & Bradstreet (DUNS) Number:

Email Address*

Phone Number*

Fax Number

Website

Principal Officers*

Polydyne Sales Representative

INVOICING ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SHIPPING ADDRESS*

Same as Invoicing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

TAX INFORMATION

Tax Exempt?

Yes

No

Tax Certificate*

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB, Max. files: 10.

BANK REFERENCE

Name of Bank*

Bank Account Number*

Banking Officer*

City/State*

Phone*

Fax

Email

TRADE REFERENCES

Trade Reference #1*

Trade Account Number*

Contact Person*

City/State*

Phone*

Email

Fax

Trade Reference #2*

Trade Account Number*

Contact Person*

City/State*

Phone*

Email

Fax

Trade Reference #3*

Trade Account Number*

Contact Person*

City/State*

Phone*

Email

Fax

CREDIT INFORMATION

Credit Line Requested*

Preferred Method of Payment*

ACH Payment

Wire Payment

Check

Credit Card

Letter of Credit

APPROVAL

I have read and understood the CERTIFICATIONS, TERMS, & CONDITIONS set forth in the section below.*

Yes

Electronic Signature*

First Last

Title*

Date*

MM slash DD slash YYYY

CAPTCHA

POLYDYNE CERTIFICATIONS, TERMS, AND CONDITIONS

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