Medeco Account Number (If applicable)______
Business/Credit Application
Please complete sections 1 through 8 and sign at section 11 for a Credit Card Account with Medeco.
Complete all sections to be considered for an open line of credit.
[1]Legal &DBA Name______
(If business is incorporated under a different name, please provide the corporate name as well)
[2]Company Address______
Street Address
______
CityStateZip
Telephone/Fax/Email(______)______(______)______
Telephone # Fax # E-mail Address
[3]Billing Address______
(If different from the address listed above)
Billing Phone/Fax/Email: (______)______(______)______
Billing Telephone # Billing Fax # Billing E-mail Address
Contact person for payments: ______
NameTitle
[4]Company President/CEO/Owner______
[5]Type of Financial Statements Attached:[ ] Prepared by Outside Accountants[ ] Prepared Internally
[6]Estimated Annual Sales Potential with Medeco:From $______to $______
[7]Approximate Value per Shipment with Medeco:From $______to $______
[8]Your preferred payment method: (Also applicable if you are applying for credit and it is denied or has not been approved by the time your first order is ready to ship)
[ ] Prepaid [ ] Credit Card: Card #:______Exp. Date:______AMEX Visa MC
(Circle One)
[9]BANK REFERENCE______
Bank NameAccount #
______
Complete AddressPhone #
[10]TRADE REFERENCES - Please complete to be considered for a credit line
(Direct manufacturer references preferred. References should meet or exceed desired credit limit. )
a)______
Company NameAcct #Avg. Credit LineFax # Phone #
b)______
Company NameAcct #Avg. Credit LineFax # Phone #
c)______
Company NameAcct #Avg. Credit LineFax # Phone #
d)______
Company NameAcct #Avg. Credit LineFax # Phone #
[11]GENERAL PROVISIONS (All applicants must sign below)
In consideration of opening an account or of granting open account credit terms, the undersigned authorizes Medeco to verify or obtain credit references on the information provided above and agrees to the provisions below if credit is extended;
a) I/we agree to pay all debts incurred within the terms of sale. However, should the debt become past due I/we expressly agree (subject to statutory regulations) to pay all finance charges on the past due amounts at the rate of 1 1/2% per month (18% annual rate). I/we further expressly agree to pay all reasonable collection costs and/or attorney’s fees incurred in connection with the collection of this account.
b) If at anytime this account becomes delinquent by more than thirty days I/we expressly agree that Medeco may have the right to terminate all contractual agreements (with proper contract notification) with this account to purchase and service Medeco products.
Print Owner/Officer Name/TitleAuthorized SignatureDate
**ATTACH RESALE CERTIFICATE FOR ALL SHIP TO STATES**
ATTACH MOST RECENT YEAR END & MONTH END FINANCIAL STATEMENTS
CUSTOMER NAME______ACCT #: ______
CREDIT TERMS______LIMIT: $ ______
MEDECO USE ONLY
Medeco Sales Representative______
Region/Terr
MARKET CODE:[ ] 1 – Door Security[ ] 2 – Industrial Sales, Mechanical
[ ] 3 –ASSA ABLOY Intragroup [ ] 4 - Export
[ ] 6 –Industrial Sales, Electr.[ ] 8 - Inter-Company, Canada
DOOR SECURITY[ ] 100 – Regional L/S Wholesaler[ ] 106 – Program Locksmith
[ ] 101 – Gen. Hardware Wholesaler[ ] 107–OEM Partner
[ ] 102 – National L/S Wholesaler[ ] 110 – Contract Hardware
[ ] 103 – Institutional Service Ctr.[ ] 111–SpecificationCenter
[ ] 104 – Non-Program Locksmith[ ] 160 – MSC Dealer
INDUSTRIALMechanical (Segment 2)Electro-mechanical (Segment 6)
[ ] 201– Laundry/Car Wash[ ] 209 – Bell Operating Co.
[ ] 202 – Vending, Games, Coin-op[ ] 218 – Vending
[ ] 203 – Alarm[ ] 219 – Gaming
[ ] 204 – Business Machines/Cntrl[ ] 230 – V-lock Sales
[ ] 205 – Safes/Lock Boxes[ ] 231 – Electronic T-handle
[ ] 206 – Communications[ ] 240 – PLS Parking Meters
[ ] 207 – Government-Related[ ] 242 – ServiceCenter
[ ] 208 – Telephone Mfg.
[ ] 210 – ServiceCenter
[ ] 211 – Auto Security
[ ] 212 – Elevators
[ ] 213 – Municipalities
[ ] 214 – Locker Manufacturers
[ ] 215 – Parking Meters
[ ] 216 – IBM
[ ] 220 – ATM
[ ] 221 – Gaming
[ ] 222 – ServiceCenter, Gaming
[ ] 241 – Mechanical Parking Meters
[ ] 250 – New Mechanical Account
[ ] 299 – Misc. Industrial
Price Level:*______% off LIST*If price level is to vary by product type/line, indicate price level for each product type/line where applicable.
______
FOR OFFICE USE ONLY:
Credit Risk Class:______(1=Low, 3=Average, 5=High)Credit Risk Score:______(1=Highest Risk, 100=Lowest Risk)
PAYDEX:______(80=Within terms, 77=5 Days Beyond Terms, 65=19 Days Beyond Terms)
Commission Code______Market Code______Segment Code______
3625 Alleghany Drive*P.O. Box 3075*Salem, Virginia24153
Phone (540) 380-5000* Facsimile (540) 380-1612*E-mail: Rev: 11/09