Company Information
Legal Company Name or Corporate Name:
Doing Business As:
Company Website Address:
Year Business Started:
Number of Employees:
Last Month of Fiscal Year:
January
February
March
April
May
June
July
August
September
October
November
December
Annual Revenue for Most Recent Fiscal Year in USD:
< $1M USD
$1M - $10M USD
$10M - $50M USD
$50M - $100M USD
$100M - $500M USD
$500M - $1B USD
$1B+ USD
Decline to answer (non-answer my prevent Spectra Logic from properly assessing credit worthiness)
If Yes, attach most recent year-end financial statements here:
Duns & Bradstreet Number:
Primary Company Phone:
Mailing Address:
City/Town:
State:
International
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
IllinoisIndiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
MontanaNebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
PennsylvaniaRhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Province/State (if international):
ZIP/Postal Code:
Country:
United States
Canada
Mexico
United Kingdom
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Armenia
Aruba
Australia
Austria
Azerbaijan
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire
Bosnia and Herzegovina
Botswana
Bouvet Island (Bouvetoya)
Brazil
British Indian Ocean Territory (Chagos Archipelago)
British Virgin Islands
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kazakhstan
Kenya
Kiribati
Korea
Korea
Kuwait
Kyrgyz Republic
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Netherlands)
Slovakia (Slovak Republic)
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia & S. Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard & Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Virgin Islands
U.S. Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
If yes, please submit applicable tax exemption/resale documentation:
Tax ID Number
Parent Company Name (if you are a subsidiary):
Parent Company Phone (if you are a subsidiary)
Contact Information
Owner/CEO Name:
Owner/CEO Phone:
Accounts Payable Contact Name (for payment inquiries):
Accounts Payable Contact Phone (for payment inquiries):
Accounts Payable Contact Email (for payment inquiries):
Invoice Submission Instructions (Email Address, Portal Web Address, Etc.):
Finance Contact Name:
Finance Contact Phone:
Finance Contact Email:
Bank Name:
If Yes, Credit Amount Currently Available (USD):
If Yes, Line of Credit Account Number:
If Yes, Credit Limit:
Bank Contact Name:
Bank Contact Phone:
Bank Contact Email:
Supporting Documentation
Attach any supporting documentation which should be referenced for credit consideration (credit references, company/organization credit overview forms, etc.
Order Information
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:
Notes/Comments About Your Credit Application:
By submitting this application, you hereby certify that the information contained herein is complete and accurate. Additionally, by submitting this application, you acknowledge Spectra Logic is not obligated to extend credit. All purchases are subject to the terms of sale found HERE .
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