Security Newdealercreditapplicationform User Manual New Dealer Credit Application Form
Newdealercreditapplicationform NewDealerCreditApplicationForm NewDealerCreditApplicationForm Dealer Forms English-US s Collateral
2017-08-09
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Application for Open Credit
Name of Firm:________________________________________________________________________________
Mailing Address:______________________________________________________________________________
City:________________________________________ State:_____________
Zip:________________________
Tel:____________________________________ Fax:______________________________
Dun and Bradstreet#_____________________________ E-mail address:_____________________________
Officers or Owners of Firm:
1._________________________________________________ Title:______________________________
2._________________________________________________ Title:______________________________
Sole Owner, please complete this section:
Name:_____________________________________________
Home Address:_______________________________________________________________________________
City:________________________________________ State:_____________
Zip:________________________
Home Tel:__________________________________
Year Established:____________________________ Business Incorporated? Yes _____ No ______
Primary Banking
Bank Affiliation:____________________________
Address:_______________________________________
Tel:_______________________________________ Fax:_________________________________________
Bankers Contact:____________________________
Acct#:_________________________________________
Loan Acct#:________________________________ Personal Acct#:_______________________________
I authorize Vicon Industries Inc. to obtain credit information for Officers, Partners or Owner(s). I (we) consent that
you may release credit information relative to my account, as named above, to Vicon Industries Inc.
Name (Print):_________________________________________________________________________________
Title:___________________________________ Signature:________________________________________
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Trade References (3 required, preferably within Security Industry)
1. Name:______________________________ Tel:_________________________ Fax:_____________________
Address:___________________________________________________________________________________
Acct#______________________________
2. Name:______________________________ Tel:_________________________ Fax:_____________________
Address:___________________________________________________________________________________
Acct#______________________________
3. Name:______________________________ Tel:_________________________ Fax:_____________________
Address:___________________________________________________________________________________
Acct#______________________________
Maximum credit being applied for: $__________________________________________
Please furnish a copy of your Resale or Tax Exemption Certificate. (Without this copy, you will be charged Sales
Tax.) For credit lines of $25,000.00 or more, please furnish a copy of your latest Financial Statement.
Credit cannot be established without this information.
Terms: Net 30 days. FOB Hauppauge, New York
Disclosure Statement:
All invoices are due on a net 30 day basis. We understand and agree that Vicon Industries Inc. has our permission
to conduct a credit investigation including, but not limited to, bank and trade references and credit bureaus. If
this account goes out of terms, we agree that Vicon Industries Inc. may assess us, and we agree to pay reasonable
late charges (not to exceed 2% per month as permitted by law), attorney fees, collection agency fees and other
costs associated with their collection efforts. The laws of the State of New York shall govern our relationship.
In consideration of Vicon Industries Inc. extending credit to the Company shown on this application, the
undersigned jointly and severally agree to be personally liable for the payment of any amounts owing to Vicon
Industries Inc.
By: (Signature)_______________________________________ Title____________________________________
Date:______________________
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Customer Profile:
Business Name:______________________________________________________________________________
Owner:______________________________________________________________________________________
Street Address:_______________________________________________________________________________
City:__________________________________ State:___________________ Zip:________________________
Tel: ___________________________________ Fax:_______________________________________________
Email:______________________________________________________
Website Address:______________________________________________
Number of Employees:______________ Number of CCTV Sales People:__________
Years in Business:__________________
Dealer Contact (Name and Title) ________________________________________________________________
Dealer Manager (Name and Title)_________________________________________________________________
End-User Orientation:__________________________________________________________________________
Description of Dealer’s Business:_________________________________________________________________
Present Video Supplier:_________________________________________________________________________
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