Credit Application Form

Please fill out the form below. This information will be sent to the Visiplex accounting department. Please email/fax any certifications or documents that would be applicable, such as tax-exempt certifications, school budget statements, etc.

Only fields with an asterisk are required.

Public schools (does not include Charter schools) can skip the trade reference section and instead email their current school budget to info@visiplex.com

Visiplex Quote Number

Visiplex Order Number

Customer Account Number

General Information

Legal Name of Organization *

Parent Company

Organization Type *

Federal Tax ID Number (EIN) *

Type of Business *

D&B Number

Year Established *

Number of Locations *

At Present Location Since

Business Address *

City *

State *

Zip Code *

Account Payable Contact *

Account Payable Email *

Account Payable Phone *

Account Payable Fax

Mailing Address

Check if Invoice Mailing Address is the Same as Above

Invoice Mailing Address

Invoice Mailing City

Invoice Mailing State

Invoice Mailing Zip Code

Shipping Address

Check if Shipping Address is the Same as Above

Shipping Address

Shipping City

Shipping State

Shipping Zip Code

Officers/Principals Information

Officer/Principal Name

Title

Officer/Principal Name

Title

Officer/Principal Name

Title

Bank Information

Bank Name *

Account Number *

Contact Name *

Contact Email *

Contact Phone *

Contact Fax

Trade References

Organization Name *

Account Number *

Contact Name *

Contact Email *

Contact Phone *

Contact Fax

Organization Name

Account Number

Contact Name

Contact Email

Contact Phone

Contact Fax

Organization Name

Account Number

Contact Name

Contact Email

Contact Phone

Contact Fax

Submission

I authorize the above references to release any information related to the above accounts.

I agree with Visiplex Terms of Sale.

Certifications/Documents

Choose File

Officer's First Name *

Officer's Last Name *

Officer's Title *

Date *