Please leave this field empty.

Company Information

Legal Company Name or Corporate Name: *

Doing Business As: *

Company Website Address: *

Company Form: *

Government EntityPrivate CorporationPublic CorporationPartnershipProprietorshipOther

Business Type: *

Value Added Reseller (VAR)Corporate ResellerOEMConsultantDistributorRetailEnd UserOther

Primary Customer Focus (if reseller):

Government/EducationEnterprise BusinessesSmall-Medium BusinessInternational/TradingOther

Year Business Started: *

Number of Employees: *

Last Month of Fiscal Year: *

—Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Annual Revenue for Most Recent Fiscal Year: *

Profitable for Two Most Recent Fiscal Years: *

YesNo

Do You Have Audited Financial Statements? *

YesNo

Duns & Bradstreet Number:

Primary Company Phone: *

Mailing Address: *

City/Town: *

State: *

—Please choose an option—InternationalAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinois IndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontana NebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvania Rhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP/Postal Code: *

Province/State: *

Country: *
—Please choose an option—USACanadaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts & NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslaviaZaireZambiaZimbabweother

Tax Exempt: *

YesNo

If yes, please submit applicable tax exemption/resale documentation to CreditCommittee@spectralogic.com.

Tax ID Number:

EIN #VAT #GST #Other Tax #

Parent Company Name (if you are a subsidiary):

Parent Company Phone (if you are a subsidiary)

Contact Information

Owner/CEO Name: *

Owner/CEO Phone: *

Owner/CEO Email: *

Accounts Payable Contact Name: *

Accounts Payable Contact Phone:*

Accounts Payable Contact Email:*

Finance Contact Name: *

Finance Contact Phone:*

Finance Contact Email:*

Bank Information

Bank Name: *

Bank Account Type: *

CheckingSavings

Bank Account Number: *

Bank Line of Credit:*

YesNo

If Yes, Line of Credit Account Number:

If Yes, Credit Limit:

Bank Contact Name: *

Bank Contact Phone: *

Bank Contact Email: *

Supplier 1 Credit Reference

Supplier 1 Company Name *:

Supplier 1 Accounts Receivable (AR) Contact Name *:

Supplier 1 AR Contact Phone *:

Supplier 1 AR Contact Email *:

Supplier 1 Account Number *:

Supplier 2 Credit Reference

Supplier 2 Company Name *:

Supplier 2 Accounts Receivable (AR) Contact Name *:

Supplier 2 AR Contact Phone *:

Supplier 2 AR Contact Email *:

Supplier 2 Account Number *:

Supplier 3 Credit Reference

Supplier 3 Company Name *:

Supplier 3 Accounts Receivable (AR) Contact Name *:

Supplier 3 AR Contact Phone *:

Supplier 3 AR Contact Email *:

Supplier 3 Account Number *:

Order Information

Currency of First Order: *

US DollarCanadian DollarEuroUK Pound SterlingAustralian Dollar

Estimated Amount of First Order (in US Dollars): *

Anticipated Annual Spectra Logic Purchases (in US Dollars): *

Name of Person Completing Credit Application:*

Title of Person Completing Credit Application: *

Date: (YYYY-MM-DD format)*

Notes/Comments About Your Credit Application: *

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