| Company Name: |
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| Street Address: |
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| City: |
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| State: |
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| Zip Code: |
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| Country: |
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| Phone Number: |
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| Fax Number: |
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| Please select one of the following: |
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| If other, please fill in: |
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| If NOT
a corporation, please complete the following: |
| Date
Opened: |
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| Principal's
Name: |
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| Title: |
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| Social
Security # |
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| Complete
Home Address: |
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| (please
specify street, city, state, zip code and country if applicable.) |
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| If
a dealer, please complete the following: |
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| What
geographic areas do you focus on? |
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| What
products/markets do you focus on? |
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| How many
sales people do you have ? |
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| Annual
Sales for 1998? |
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| Annual
Sales for 1999? |
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| Contact
Names: |
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| President
/ CEO |
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| CFO |
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| Sales /
Marketing |
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Accounts Payable |
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Bank Reference: |
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|
Name: |
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|
Complete Address: |
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| (please
specify street, city, state, zip code and country if applicable.) |
|
Contact Name: |
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| Phone Number: |
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| Fax Number: |
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| Date Opened: |
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| Type of Account: |
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| Checking
#: |
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| Savings #: |
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| Loan #: |
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| Credit
References: |
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| Reference
1 |
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| Name: |
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| Complete Address: |
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| (please
specify street, city, state, zip code and country if applicable.) |
| Contact Name: |
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| Phone Number: |
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| Fax Number: |
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| Account Number: |
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| |
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|
| Reference
2 |
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| Name: |
|
| Complete Address: |
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| (please
specify street, city, state, zip code and country if applicable.) |
| Contact Name: |
|
| Phone Number: |
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| Fax Number: |
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| Account Number: |
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| |
|
|
| Reference
3 |
|
| Name: |
|
| Complete Address: |
|
| (please
specify street, city, state, zip code and country if applicable.) |
| Contact Name: |
|
| Phone Number: |
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| Fax Number: |
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| Account Number: |
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| |
|
|
| Reference
4 |
|
| Name: |
|
| Complete Address: |
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| (please
specify street, city, state, zip code and country if applicable.) |
| Contact Name: |
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| Phone Number: |
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| Fax Number: |
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| Account Number: |
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| General
Information: |
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| Any prior
history of bankruptcy or reorganization under bankruptcy law? |
Yes
| No |
| If
"yes" when? |
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| Will you
be purchasing Pryor products for resale? |
Yes
| No |
| If
"yes", please provide your resale card number: |
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| Electronic
data submission and signature:
To the best of my knowledge the
above facts are true. If approved, we agree to Pryor Products Terms and Conditions. Submission of
this data indicates our permission for Pryor Products to obtain
credit information from the sources referenced an any external
reporting source. This agreement is entered into and is to be
performed under the laws of the State of California. I am
authorized by my company to enter into this agreement.
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| Submitting
Individual: |
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| Title: |
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| Date: |
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