BusinessIQ

General Information

Credit Limit Requested
$

Company Information

^*Business Name

Doing Business As (DBA Name)

^*Tax ID

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Country

^*Accounts Payable Contact Name

^*Telephone

^*Email Address

^*Telephone - Work

Legal Structure

Type of Business

SIC Code

NAICS Code

Number of Employees

Year Business Established

^*Application Contact Name

^*Telephone - Work

Telephone - Cell

^*Application Contact Email Address

Mailing Address

Mailing Address2

City

State/ Province

Zip/Postal

Purchasing Contact Name

Purchasing Contact Telephone

Purchasing Contact Email Address

Country

Other Locations

How many other Locations?

How did your hear about Markertek?

Business Operates From?

What Products are you interested in?

Do you prefer email billing?

Provide email address for billing

Has firm ever been bankrupt?

If past or present bankruptcy, why?

Resale/sales Tax Number

Do you wish to recieve company news and promotional email from Markertek?

Trade Reference Information

^*Reference Name

Fax Number

^*Contact Name

^*Phone Number

^*Contact Email

^*Reference Name

Fax Number

^*Contact Name

^*Phone Number

^*Contact Email

Bank Reference Information

^*Bank Name

^*Bank Phone Number

Bank Fax Number

Bank Email Address

^*Bank Contact Name

Principal / Guarantor Information

Principal Type

Principal First Name

Principal Middle Name

Principal Last Name

Principal Home Address

City

State/ Province

Zip/Postal

Telephone - Home

Telephone - Work

Telephone - Cell

Principal Email Address

Principal Social Security Number (SSN)

^*Are you willing to Personally Guarantee (Y/N)
Yes No

Personal Guarantee

^*Signature Of Guarantor

^*Title

^*Date

Collateral

Collateral Market Value
$

Ownership Stake in Collateral

Attachments

PLEASE INCLUDE SIGNED CERTIFICATE OF RESALE/TAX EXEMPT FORMS IF APPLICABLE. If you have difficulties attaching or uploading files, please email them directly to credit@markertek.com

Attachment Description

Attachment Location

Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.

Terms and Conditions

^*Signature of Applicant

^*Title

^*Date

PRINT AGREEMENT

I agree to the terms and conditions specified above.

User Verification

Please complete the following by entering the value EXACTLY how it appears(case sensitive)

Why do I have to do this?