Exloc Customer Profile 60 Form

Customer Profile Form
Exloc Instruments, Inc.
15584 Summit Park Drive, Suite 303
Montgomery, TX 77356
281-978-2040
Company Legal Name*
Company Name
Year Established*
Billing Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Shipping Address (if different from billing address)
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code

Accounts Payable (A/P) Contact Name*
First NameLast Name
A/P Phone Number*
A/P E-mail Address*
example@example.com
Dun & Bradstreet (Duns#)
FEIN
Upload a completed copy of your W9 form here.*
Cancelof
Tax Exempt?*
Applies to TX, VA, NC, TN, LA, KS and GA.
Upload a copy of your sales tax exempt certificate here.
Cancelof
Has your company ever filed for bankruptcy?*
If yes, please answer questions below.
When?
Status?

Credit References*
Name Company Phone No Email
Trade Reference #1
Trade Reference #2
Trade Reference #3
Bank Reference
How to you hear about us?
If other, please indicate in the field below.
Other
Exloc’s Payment Terms and Conditions
(Information below cannot be changed or modified by the customer)
1. Exloc Instruments AGREED domestic payment terms are Net 60. If payment is not made within 60 days of invoice date an 18% annual 1 ½% monthly late fee may be assessed and customers account will be placed on hold.
2. All accounts over 75 days may be submitted to collections. ALL fees incurred during the collections process are the responsibility of the customer and must be paid in full.
3. A $35.00 fee will be assessed for all returned checks.
  All international orders are to be paid in advance by wire transfer and a $25.00 fee is assessed for all international wire transfers.
4. For your convenience we also accept domestic ACH, Visa, Master Card or American Express.
  
  We thank you for your business and prompt payment.
Signature*
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