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Applicant Company Information
Company Name:
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
Credit Limit Request:
Number of Employees:
Years in Business:
Federal Tax I.D.#:
Resale Tax No.:
If publicly trade company, please provide symbol:
Contact Name/Phone for Accts. Payable:
Principle Owner/Officer Information
Principal Owner/Officer Name (1):
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Principal Owner/Officer Name (2):
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Bank References
Primary Bank Name (1):
Bank Address 1:
Bank Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
Account No.:
Secondary Bank Name (2):
Bank Address 1:
Bank Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
Account No.:
Trade References
Company Name (1):
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Account No. :
Company Name (2):
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Account No.:
Company Name (3):
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Account No.:
Company Name (4):
Address 1:
Address 2:
City:
State:
Zip/Postal Code:
Country:
Phone:
Account No.:
Authorization and Governing Law

This application for credit constitutes an agreement which will be entered into and shall be governed by and construed in accordance with the procedural and substantive laws of the State of California. By the execution of this Agreement, Customer agrees to be subject to the jurisdiction of the Courts of the State of California in case of any disputes. The customer further agrees to be subject to the trading terms of Cybernet Manufacturing, Inc.

I agree to abide by the terms stated above and authorize the above mentioned bank(s) and trade references to release the information requested by CYBERNET MANUFACTURING, INC. required to establish an account under these terms.



Authorized Officer's Signature Print Name Date
Authorized Bank Account Signatory Print Name Date


Once you have completed this form, please print, sign and return via fax to
Cybernet's credit department at 949-600-8001 or 949-600-8013

Copyright ® 2001 - 2010 Cybernet Manufacturing, Inc. All Rights Reserved.
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