STEP 2 - Credit Application Form

Please fill out, click display, print, sign and fax this form to: (800) 767-9722 before proceeding to Step 3.

The following information must be completed in full, and will be kept in the strictest confidence.

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Part 1

Company Name:

Phone:   Fax:   Website:

Resale #:    Federal Tax ID #:

Type of Business:  Corporation  Partnership  Proprietorship    How long in business:

Title Officers in responsible parties Driver's Lic. # Social Security# Email Address --- Select --- Owner/President Buyer/Purchasing Agent Accounts Payable Other   --- Select --- Owner/President Buyer/Purchasing Agent Accounts Payable   --- Select --- Owner/President Buyer/Purchasing Agent Accounts Payable

Access to the ACM eCatalog for ordering products online: Name Title Email Choose a Password

Terms: (**MUST ATTACH A COPY OF THE RESALE LICENSE AND SIGNED CERTIFICATE)   COD/Cashier Check ($1,000 limit)   COD $300 limit (**Must attach a copy of voided blank check)   Credit Card $1,000 limit (Must fill out the authorization form on step 4)   TT-Wire Transfers Acct #

Business/Bill To Address:

City:    State:    Zip:    Country:

Check this box if your shipping address is the same as your billing address.

Ship To Address:

City:    State:    Zip:    Country:

Part 2

Current Major Suppliers 1

Name:

Phone:    Fax:

Address:   City:    State:    Zip:

Account #:   Terms:   Credit Line $:

Current Major Suppliers 2

Name:

Phone:    Fax:

Address:   City:    State:    Zip:

Account #:   Terms:   Credit Line $:

Current Major Suppliers 3

Name:

Phone:    Fax:

Address:   City:    State:    Zip:

Account #:   Terms:   Credit Line $:

Part 3

Bank Reference

Bank Name:

Phone:    Fax:

Address:   City:    State:    Zip:

Account #    Date Open:

Part 4  (Optional)

No. of Technicians:   Are you an authorized dealer? Yes   No  If so, what brands

What brands do you carry?  Brother Canon Copystar Gestetner Kyocera Mita Konica Minolta Panasonic Ricoh Riso Samsung Sharp Toshiba Xerox  Other

What is your business focus?:  Image Supplies OEM Compatible  |  Parts OEM Compatible Equipment - What brands? Color MFP - What brands?

Do your customers order from your web site? Yes - Web Address

I would like to be informed of promotions via: Fax Email Mailing No, do not send it to me

How did you hear about ACM Technologies, Inc.?  Magazines: ENX imageSource Locater Search Engine thecopiernetwork.com Email Blast Fax Flier Trade Show ACM Mailing Piece Friends Other

Part 5

I certify that all of the above information on this form is correct.

Read Carefully: I personally guarantee all debts incurred by the firm listed in Part (1) of this application form and accept full responsibility for all debts. I further agree to keep within your terms of granted open account. Should this account ever become delinquent and it be necessary to employ an attorney to collect or commence suit to enforce payment, I agree to pay a reasonable additional sum as attorney fees, and the cost of such suit. A late charge of 1-1/2% will be charged on all past due accounts. Unit credit approval can be obtained, new accounts will be shipped C.O.D. Cash or Credit Card.

Authorized signers on account:_______________________________________________________________________

Name:____________________________  Title:_______________________________  Date:______________________

Please click Print and Sign this page before continuing to Step 3

Clicking Display will not send any information. It will only change the appearance of the form in order to print.