APPLICATION FOR CREDIT


BY: ___________________________________________________

NAME OF FIRM OR INDIVIDUAL

___________________________________________________ YEARS AT THIS ADDRESS ___

ADDRESS

_________________________________________________________________________

CITY STATE ZIP CODE AREA CODE PHONE

 

HEREBY applies for credit in accordance with the terms and conditions of MSE Media Solutions.

The following information must be provided. It will be held in the strictest confidence.

 

OWNERSHIP: ___ Corporation ___ Check here if incorporated within the past 12 months ___ Partnership ___ Individual

NAMES(S) OF PRINCIPAL(S) COMPLETE ADDRESS ZIP CODE AREA CODE PHONE

1.) __________________________________________________________________________

2.) __________________________________________________________________________

3.) __________________________________________________________________________

4.) __________________________________________________________________________

 

FINANCE:

___________________________________________________________________________

BANK BANK ADDRESS

______________________________________________________________________

BANK OFFICER, OR DEPARTMENT ACCOUNT NUMBERS

 

REFERENCES:

BUSINESS NAME COMPLETE ADDRESS ZIP CODE AREA CODE PHONE
1. ________________________________________________________________________


2. ________________________________________________________________________

 

3. ________________________________________________________________________

 

4. ________________________________________________________________________

 

_____ Check here if cash sales are okay until credit is approved. We certify that all the information on this form is correct. We fully Understand your credit terms and agree to the proper payment in Consideration of extended credit.

(Signed) ______________________________

Date _____________, 20____ Title ________________________________

 

6013 SCOTT WAY * LOS ANGELES, CA 90040 * 323 721 1656 * 800 626 1955 * FAX 323 721 1506

Web site: www.msemedia.com e-mail address: mse@msemedia.com