p Reseller Application

American Sunrex Corporation
Credit Application Form:
Address: 671 Brea Canyon Road, Suite #1 Walnut, CA 91789 U.S.
Tel: 909-839-1985   Fax: 909-839-0254

Note: Please fill this form out completely.  You can SUBMIT this form through our secure email server or print and submit to us via fax or download MS Word format. Our fax number is 909-839-0254.  This information will not be passed on to anyone else.

APPLICANT COMPANY INFORMATION

Company Name:

 

Address:

 

City, State, Zip:

   

Phone, Fax, Amount Request:

    US$

Number of Employees:

 

Years in Business:

 

Federal Tax I.D. #

 

Resale ID #

 

Principle Function of Business:

 

Contact Name for Accounts Payable:

 

Telephone Number for Accounts Payable:

 
 

PRINCIPAL OWNER/OFFICER INFORMATION

Principal Owner/Officer Name:

 

Home Address:

 

City, State, Zip:

   

Social Security Number:

 

Principal Owner/Officer Name:

 

Home Address:

 

City, State, Zip:

   

Social Security Number:

 

BANK REFERENCES

Bank Name:

 

Bank Address:

 

Bank Phone, Fax:

 

Account Number:

 

Bank Name:

 

Bank Address:

 

Bank Phone, Fax:

 

Account Number:

 
 

TRADE REFERENCES

*Regretfully, American Sunrex cannot accept trade references from Tech Data or Ingram Micro as they decline to provide credit references for their clients.

Company Name:

 

Address:

 

Phone and Fax:

 

Account Number:

 

Company Name:

 

Address:

 

Phone and Fax:

 

Account Number:

 

Company Name:

 

Address:

 

Phone and Fax:

 

Account Number:

 

Company Name:

 

Address:

 

Phone and Fax:

 

Account Number:

 
 

AUTHORIZATION and GOVERNING LAW

 

Authorized Officer:

 

Date:

 
Validate code: