ITW
Credit Reference Information
Bank Reference:
Bank Name: 2~t F+'6ISl;/V 'bA-r/Jk Or. d.
Address: 3/rN It ;OS ( pf! ,7c=-t. ftCt c 4 ;f
Phone: -+'!:>t?[ 23 207' ..300
City State / Province, 2 ;1J-J 4-12 2 300 .::J
Zip Code & Country: CILOA7/
n A-
Trade Reference #1:
Name: DO(I/rJ d·o.o.
Address: ;L4-LIiHI12.0c/4 IC( ~
City State / Province, [Link] /027'0
Zip Code & Country:
C WA:114
Trade Reference #2:
Name: clo. o.
Address:
City, State / Province, SOLIN 2,1 21.0
Zip Code & Country:
C !2-.0 A-f ( 4
Yearly
Ownership Type: @Sole Owner o Partnership o Corporation Sales (USD):
Principal: J}Nc-F tV!A-t~1 ~OJ( L {.7 FN (? f44-t. /J. V\-'I\J A-G;ff
(Name) (Title)
Principal: /u ~ ,M117'2-t -r N -!)v ( C-
(Name)
Principal:
(Name) (Title)
Accounts Payable Contact: fllfd-I c4 j (!3:>12 I IrtL
f:-A) / Email: (IJ-f ~ C(C/r('~. 4v
Title: l/-CcDu i0 111.1q 1Mbu,fc; rt2 Phone: i ~g.r 7''/ /0Z'9 4 Cj.~
ITW n
INTERNATIONAL CUSTOMER SCREENING & CREDIT FORM
.RETURN BY FAX: (001)-913-397-8707 or EMAIL: cservice@[Link]
General Company Information
Company Name: do Ii... 0 )'0. <D.
A-IV/~ f.1 A-cTI Aj Ou (C.
Contact Person: 9..Mrs:" /.Ms'.
Business Address: {' V- V I AJ Ii.. 1+ ?Au L .5 1<-<0 C; ;2
City, State/Province, Z/}j)lt2- Q 21000
Zip Code & Country: (c-O A-r/ 4-
C- r.7
Phone Number: ~ Fax Number: r-
(with country code) -t'; ~.l c;;1 ,1!Yoo 1sD (with country code) -T 3g .l
Email: q brYJ ~ OlD!Oc,IP V 0 fJ - /1 V-
v
Website:
D End User 0"Distributor Date Number of years at
Type of Business: Established: /191 this address: /,6
D Wholesaler D Other:
Shi.l!l!i!!gInformation
Shipping Street
Address:
City, State / Province,
Zip Code & Country:
Shipping Contact Phone:
Name:
Email:
Freight Forwarder Information
Company Name:
Street Address:
City, State / Province,
Zip Code & Country:
Phone:
Contact Person:
Fax:
Title:
Email:
IITW on
BY YOUR SIGNATURE BELOW, YOU GRANT ITW DYMON PERMISSION TO VERIFY THE
INFORMATION WITH THE ABOVE REFERENCES AND YOU AGREE TO BE BOUND BY THE
FOLLOWING CREDIT TERMS, IF GRANGED BY ITW DYMON, ON ALL INVOICES ISSUED ON
OR AFTER TillS DATE.
All accounts are due and payable not more than thirty (30) days from their respective dates. Any unpaid
amounts shall bear interest at the rate of Eiz % per month (18% Annual Percentage Rate) from and after the
thirtieth day following their respective dates. If the foregoing interest rate is not lawful where the purc4ase is
made, then substitute the maximum legal rate of interest applicable in that state or legal jurisdiction. Title to
any goods sold shall remain vested in the Seller until such goods shall have been paid in full. Should Seller fmd
it necessary to engage others to collect past-due monies from the undersigned or his/her company, the
undersigned agrees that (s)he or his/her company will pay all costs of collection, including, but not limited to
attorneys' fees and court costs, both at trial and upon appeal.
Any misrepresentation in this application will be considered evidence of fraud since this information is the basis
for granting credit.
As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct.
You are authorized to investigate the credit references listed.
Authorized Signature:
Printed Name:
For ITW Internal Use Only
Shipping Details
Freight Payment Code: D EXW D FCA D DDU D DDP Payment Tenns:
Ship Via: Default Ship-To #: Allow B/O: D YES D NO
Salesperson
Sales Reps Name: Sales Rep #:
Miscellaneous Details
Market Code: Customer Class:
