Online Credit Application

Sales: [email protected] / +1 301 975 1000
Support: [email protected] / +1 301 975 1007

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COMPANY INFORMATION
Company Form:	Subsidiary of:

Public Corp. Stock Symbol:	Are you in bankruptcy?:
	No Yes
Federal Tax ID:	Have you ever filed for bankruptcy?:
	No Yes
D&B Number:	Tax Exempt:
	No Yes
Telephone:	Fax:

Company Name:

Address Line #1:

Address Line #2:

City:	State:	Zip:

Country:	In Business Since:

Web Address:

Name of Applicant:

Email Address of Applicant:

BILLING INFORMATION
Patton Electronics delivers invoices and statements by email. We will deliver to multiple email addresses. Invoices and statements delivered by email will be in PDF format. To view and print PDF documents you will need Adobe Acrobat Reader which may be downloaded at www.adobereader.com Please provide the email addresses for delivery of invoices and statements in the space provided below:
Invoices by Email:	Statements by Email:
#1: #2: #3:	#1: #2: #3:

ORDERING INFORMATION
Are written Purchase Orders required?:	Are items for resale?:
No Yes	No Yes
Resale Number:	NOTE: If items are for resale, please attach a copy of your resale certificate on the next screen.

BANK REFERENCE	Reference Sheet will be attached
Bank Name:			Contact:

Address Line #1:			Telephone:

Address Line #2:			Account #:

City:	State:	Zip:	Country:

Name:	Title:

Date:	Telephone:

I agree with and accept the Terms and Conditions stated above: Accept Do Not Accept: (Note: you MUST choose 'Accept' above in order to show acceptance for your application to be processed - if you choose 'Do Not Accept', your information will be received, but your application will NOT be processed. Thank you!)

CREDIT LINE
Requested Credit Line Amount($):