Telpar, Inc.

 

Telpar 
187 Crosby Road, Dover, New Hampshire 03820
603-750-7237 • 800.872.4886 • Fax: 603-742-9938 • Website: http://www.telpar.com


After filling out the appropriate blanks, please print and sign this form and fax it to Telpar, Inc. at (603-742-9938).


  Customer Information
Company Name   
Company Info    Year Company Founded:      DUNS Number:  
Parent Company:   
Reseller or Tax Exempt Certificate No.       Copy must be attached or tax will be charged
Accounts Payable   Address       Name       Title  
   Phone      Fax  
   Address:  
   Suite No:      City:  
   State:      Zip:  
Physical Address      Address:  
   Suite No:      City:  
   State:      Zip:  
Principal Executive   
Officers or Owners   		    Name      Title  
   Telephone      Extension  
   Name      Title  
   Telephone      Extension  
   Name      Title  
   Telephone      Extension  
  Trade References
   Company 1      Company 2  
   City      State      City      State  
   Phone      Phone  
   Fax      Fax  
   Account      Account  
  Bank Reference (For Bank Use Only)
   Bank Name  
   and Location  		    When did this account    open?      3 month average    balance:  
   Account Numbers:  
    		    Has this customer had any NSF checks?
    Yes                         No
   Contact Person:  
 		    Is this checking account satisfactory?
    Yes                         No
   Email:  
 		    Information submitted by: (Signature)
   x
   Telephone Number:  
 		   Printed Name  
  and Title:  
   Fax Number:      Date Submitted:  
We, the undersigned, do hereby certify that the information provided on this credit application is true and accurate. We further authorize Telpar, Inc. to conduct any investigation it may deem necessary to verify the accuracy of such information.
   Customer Authorization    Signature Printed Name Title Date
x