|
NET-15 FORM Credit Application |
|
Membership Information
|
MEMBER NUMBER
|
EXPIRATION DATE
|
SELECT MEMBER TYPE
[ ] GOLD [ ] SILVER [
] STANDARD |
Customer Information
|
NAME (FIRST, MIDDLE, LAST)
|
|
|
ADDRESS (PERMANENT MAILING ADDRESS)
|
|
|
CITY , STATE, ZIP CODE
|
|
|
HOME PHONE |
WORK PHONE
|
|
EMAIL |
|
|
SPOUSE NAME (OPTIONAL) |
|
Bank / Credit Reference
|
SOCIAL SECURITY NUMBER |
DRIVER’S LICENSE NO, STATE ISSUED, EXPIRATION
DATE |
|
|
BANK NAME, CITY, STATE |
||
|
BANK CONTACT NUMBER |
TYPE OF ACCOUNT [
] CHECKING
[ ] SAVINGS |
|
|
|
|
|
|
CARD NUMBER |
CARD TYPE [
] VISA [
] MC |
|
NAME ON CARD |
CARD EXP DATE |
|
NET-15 TERMS By signing below, I agree
to the NET-15 terms. I understand that I may defer invoice payments to 15-days
of the date of invoice. If my payments are not received by the due date, I may be
liable for LATE FEES of $35 per invoice. I am also liable for any collections or
court fees that may be required to collect all overdue invoices or
work-authorizations/service calls I have with MicroWiz. |
|
__________________________________________ CUSTOMER SIGNATURE |
|
Revised 06.12.2003
Click here for Fill-able form (Adobe Acrobat Reader required)