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Credit Application
Application Date: _____________
Business Name: ________________________________________________________________________
Billing Address: ________________________________________________________________________
City: _______________________________ State:_______________ Zip: _________________
Shipping Address:_______________________________________________________________________
City: ______________________________ State:________________ Zip: _________________
Phone:________________________________ Fax:____________________________________
Contact Personnel: Authorized Buyer: ______________________________________________
Accounts Payable: ______________________________________________
Date of Establishment:____________________
Type of Organization (check one) : Sole Proprietor _______ Partnership _______ Corporation _______
If Corporation, State of Incorporation:________________________________________________________
Owners or Principals (Sole Proprietor or Partnership):
1. Name: _____________________________________ Title: _______________________________
Home Address: __________________________________________________________________________
City: ___________________________________ State: _______________Zip: _______________
2. Name: ______________________________________ Title: _____________________________
Home Address: __________________________________________________________________________
City: ___________________________________ State: _______________Zip: _______________
Financial Information
Federal Tax ID Number:___________________________________________________________________
Fiscal Year End:______________________ Requested Line of Credit: $ U.S._________________________
Bank Reference
Name/Branch:____________________________________________________________________________
Address: ________________________________________________________________________________
City: _________________________________ State: ________________________ Zip: ________________
Contact Personnel: ____________________________ Account Number:____________________________
Trade References (Minimum of Three Required):
Company Contact Address Phone Fax
1) _____________________________________________________________________________________________
2) _____________________________________________________________________________________________
3) _____________________________________________________________________________________________
By Signing this application, the applicant agrees to the following provisions:
1. The business relationship between the applicant and Sensoray, if any, shall be governed by Sensoray
Standard Terms of Sale, distributor agreements (if applicable), and cost schedules. Any additional or different
terms in the applicant's business forms shall be void and of no effect.
2. The applicant agrees that the extension of credit is at the discretion of Sensoray's credit department and
accounts that become past due may be put on prepay/COD.
3. The applicant will pay all costs of collection incurred by Sensoray including attorney fees and collection
agency fees (collection fees not to exceed 25% of the total debt.), whether or not any legal proceeding is initiated.
4. The applicant understands that purchase invoices will be mailed one time (via mail post) at the time of
product shipment, and that Sensoray will not provide a follow-up invoice statement. It will be the applicants'
responsibility to pay on time as agreed under the established credit terms.
5. If items are returned
other than for defect, the customer will pay a restocking fee of 25% of the original purchase price. The customer will also pay for all shipping.
6. The information contained herein is for the purpose of obtaining credit
and is warranted to be true. I/We hereby authorize Sensoray Co., Inc. to investigate the references listed above pertaining to my/our credit and financial responsibility.
Signature/Date: ___________________________________________________________________________
Printed Name: ____________________________________________________________________________
Application must be signed in order to be processed
7313 SW Tech Center Dr., Tigard, Oregon 97223, USA
ph:(503) 684-8005 fx:(503) 684-8164
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