Partner Program Credit Application - AmZetta Technologies™

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone(Required)

Main Fax

Company Website(Required)

Type of Organization(Required)

DUNS #

Federal Tax ID #(Required)

State resale #/Exempt #

(Include a copy of your resale/exempt license)

Max. file size: 256 MB.

Company Ownership / Officers

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Fax

Name

First Last

Title

Email

Phone

Fax

Accounts Payable Contact

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Fax(Required)

Purchasing Contact

Name(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Fax(Required)

Bank Reference

If your organization has a bank and trade reference sheet you may email that to your sales rep in lieu of filling out the fields below.

Institution Name

Account #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Trade References

Reference #1

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Account #

Reference #2

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Account #

Reference #3

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Account #

Credit data is essential for AmZetta to do business with your organization; incomplete information may cause unnecessary delays. By clicking the "SUBMIT" button, I acknowledge hereby that I have authority of the Company to enter into agreements on its behalf, and agree that the information contained herein with respect to the Company and its Credit Information is accurate and correct. The processing of my personal data is described in the AmZetta Privacy Policy.

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Bank Reference

Trade References

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AmZetta Credit Application

Company Ownership / Officers

Accounts Payable Contact

Purchasing Contact

Bank Reference

Trade References

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