CONFIDENTIAL CREDIT APPLICATION
REQUEST TO ESTABLISH CREDIT WITH BURST COMMUNICATIONS, INC.
Name of Firm
--Who is your sales rep?--
---Colorado---
Don Rooney
Gary Cooper
Kirk Basefsky
Kirk Basefsky
Melissa Davidson
Robin Heywood
Robin Heywood
---California---
Greg Gorian
Rebecca Clubb
---Texas---
Barry Samuels
Debbie Goldin
Tom Smith
---New Mexico---
Thom Johnson
---Utah---
Erland Reber
Larry Fukunaga
Have you ordered from us before?
Yes
No
Requested Credit Amount:
DUNS NO.
Email
Billing Address:
Address
City
State
Zip
Phone
Fax
Shipping Address:
Same as Billing
Address
City
State
Zip
Phone
Fax
Parent Company
City
State
Taxable
Non-Taxable
(Tax Exemption Certificate is required - fax to Burst:303-649-9890)
Corporation |
Partnership |
Proprietorship
Type of Business
If Corporation, State of Incorporation
Date Business Started (mm/dd/yyyy)
President, Partner or Owner
Vice-President or Owner
Payables Contact:
Phone:
Bank References
Name
Address
City
State
Zip
Phone
Fax
Account
Officer
Name
Address
City
State
Zip
Phone
Fax
Account
Officer
Trade References
Ref 1
Name
Address
City
State
Zip
Phone
Fax
Account
Contact
Ref 2
Name
Address
City
State
Zip
Phone
Fax
Account
Contact
Ref 3
Name
Address
City
State
Zip
Phone
Fax
Account
Contact
Ref 4
Name
Address
City
State
Zip
Phone
Fax
Account
Contact
By checking this box, I certify that the above information is true and correct to the best of my knowledge and that if the foregoing application is made on behalf of a corporation, that I am authorized by its board of Directors to sign this application on their behalf.
By
Title
Date
BURST COMMUNICATIONS, INC.
8200 SOUTH AKRON STREET, SUITE 108
ENGLEWOOD, COLORADO 80112-2111
FAX: 303-649-9890
*Credit applications may take up to 2 business days to be processed.
Successful form submission does not guarantee credit approval.