Instruments & Equipment Company Dealer Application 
(Please print and complete this form. This form requires a signature.) 

Company Name _______________________________________________________________________________

Address _____________________________________________________________________________________       

City _____________________________     State _____          Zip Code________________  

Accounts Payable Contact  ________________________ Telephone or Extension ___________________________

Purchasing Contact _____________________________  Telephone or Extension ___________________________

Technical Contact  ______________________________ Telephone or Extension ___________________________

Website Address __________________________________________________ 

  Corporation     Partnership       Proprietorship

Years in Present Business ________________________      Dunn & Bradstreet # ________________________  

Sales Tax/Use Tax Exemption Certificate Number:_________________________________________________
(Please Fax a Copy of This Year's Exemption Certificate Along with this Application)

Bank Name ______________________________________________________________________________     

Bank Address _____________________________________________________________________________         

City _____________________________     State _____        Zip Code __________________________________

Bank Telephone # _______________________________     Bank Fax #      ______________________________

Bank Contact Name ______________________________    Bank Account # _____________________________  

New Jersey law shall be applied to resolve all disputes between us, and you consent to submit to the jurisdiction of New Jersey’s courts in the event a dispute arises between us which we cannot resolve ourselves.  It is further understood and agreed to that if you fail to make payments owed to Instruments & Equipment Co. in connection with the orders you place, you will be in default.  If you default on payments, we will be entitled to all damages caused as a result of your default, and you shall be obligated to pay our costs of collection and reasonable attorney’s fees.   I also authorize the release of credit and banking information to Instruments & Equipment Company.

X_________________________________________________________
 Authorized Signature of Company Owner  or Corporate Officer

___________________________________                     _____________________________________
 Title/Position                                                                                Date

___________________________________                      ______________________________________
Printed Name                                                                             Social Security #

Please Fax (after signing) to:

Instruments & Equipment Co. - 2 Wilson Dr., Unit #1 - Sparta, NJ   07871 - Fax: 973-579-6665

Please fax your completed credit application to the above address for credit processing.  Please allow us 1 to 3 business days, after we receive your initial order, to process your credit application.

TRADE REFERENCES (Major Suppliers)
 

Company Name ______________________________________________________________________     

Address ____________________________________________________________________________     

City ______________________________  State _____          Zip Code ____________________________

Telephone # ___________________________________      Fax #      _____________________________

Contact Name __________________________________     Email _______________________________   

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Company Name ______________________________________________________________________      

Address ____________________________________________________________________________     

City ______________________________  State _____          Zip Code ____________________________

Telephone # ___________________________________      Fax #      _____________________________

Contact Name __________________________________     Email _______________________________   

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Company Name ______________________________________________________________________      

Address ____________________________________________________________________________     

City ______________________________  State _____          Zip Code ____________________________

Telephone # ___________________________________      Fax #      _____________________________

Contact Name __________________________________     Email _______________________________     

If you prefer, you may attach your own trade/credit reference list and fax it along with the first part of this credit application.