Bogen Application for Credit Form

Your Bogen Regional Sales Manager

Business Information

Name of Business

DBA (if applicable)

Division/Parent Company Name (if applicable)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Applicant's Name

Applicant's Email

Applicant's Phone Number

Number of years in business

Banking Information

Bank Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Bank Contact Name

Bank Contact Email

Bank Phone Number

Bank Fax Number

Bank Account Number

Trade References

Vendor 1

Vendor Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Vendor Phone Number

Vendor Fax Number

Vendor Email Address

Vendor 2

Vendor Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Vendor Phone Number

Vendor Fax Number

Vendor Email Address

Vendor 3

Vendor Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Vendor Phone Number

Vendor Fax Number

Vendor Email Address

Vendor 4

Vendor Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Vendor Phone Number

Vendor Fax Number

Vendor Email Address

Vendor 5

Vendor Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Vendor Phone Number

Vendor Fax Number

Vendor Email Address

Vendor 6

Vendor Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Vendor Phone Number

Vendor Fax Number

Vendor Email Address

You MUST submit four references with complete information (including Fax numbers) for each reference.

All sales are subject to Bogen's terms and conditions of sale located at Terms and Conditions, which are incorporated herein and which you acknowledge will form a part of every sale.

<<<<< Authorization >>>>>

I hereby represent that I am authorized to submit this application on behalf of the Company herein named, and that the information provided is for the purpose of obtaining credit and is warranted to be true. I hereby authorize Bogen Communications, Inc., to investigate the references listed pertaining to the Company’s credit and financial responsibility. It is agreed and understood that all necessary collection and legal expense will be charged to the debtor in the event of default or failure to pay for goods sold and delivered. It is also agreed that any court appearances will be held in Bergen County, New Jersey. I further represent that the Company herein named has the financial ability and willingness to pay all invoices with established terms.

This form may be submitted electronically, and the Applicant’s signature will be treated as an original signature for all purposes.

Signature 1

Title

Date

Signature 2

Title

Date