New Account Credit Application

Reference #1

Reference File Upload (doc, docx, xls, xlsx, pdf)

Accepted file types: xls, doc, pdf, docx, xlsx, Max. file size: 256 MB.

This application will not be processed without three references. You may upload a file containing your references or complete the fields below.

Reference #1 Name

Reference #1 Email

Reference #1 Phone

Reference #1 Fax

Reference #1 Address

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

Reference #2

Reference #2 Name

Reference #2 Email

Reference #2 Phone

Reference #2 Fax

Reference #2 Address

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

Reference #3

Reference #3 Name

Reference #3 Email

Reference #3 Phone

Reference #3 Fax

Reference #3 Address

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

Bank Name

Bank Contact Name

Bank Contact Email

Bank Phone

Bank Fax

Bank Address

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

Acknowledgement

The undersigned hereby affirms that he/she has the authority to sign this document authorizing the bank to release information to Shurtape Technologies, LLC. The Applicant certifies that the information contained in this Application for Credit is true and correct and further agrees that Shurtape Technologies, LLC may turn to a credit reporting bureau for verification of the information provided. (Subsequent credit inquires may be completed by Shurtape Technologies, LLC in connection with any update, renewal or extension of credit.) The Applicant agrees to the following: Applicant herewith submits the within Application for Credit to: Shurtape Technologies, LLC as well as to their subsidiaries, divisions, affiliates and related companies. Applicant shall pay the full amount of the invoice(s) when due, which is defined to be thirty (30) days from the invoice date, unless otherwise agreed.

Your Name*

Your Email

Your Title

Signature*

New Account Credit Application

Additional Information

Reference #1

Reference #2

Reference #3

Acknowledgement