Channel Partner Group

Credit Application Form


Company Information
Company Name:
Phone:
Fax:

Billing Info
Address 1:
City:
State:
Zip:
Address 2:
City:
State:
Zip:

A/P Contact
Name:
Email:

Other Info
Type of Business:
If a Corporation:	What Type? C S
	State of Incorporation:
Business Start Date:
FEIN:
D&B No:

Banking Reference
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Account Officer:

Trade References
Company 1:
Contact:
Address:
City:
State:
Zip:
Phone:
Fax:

Company 2:
Contact:
Address:
City:
State:
Zip:
Phone:
Fax:

PLEASE NOTE: Submitting this form indicates that you accept the terms and conditions stated below:

I understand that the information submitted herewith is confidential and for the purpose of establishing a credit account with Channel Partner Group. I do hereby certify this information to be true and correct and I am authorized in my capacity to bind my company accordingly. Further, if credit is extended, and the entity is a Proprietorship, Partnership or S Corporation, the undersigned personally agrees to pay all monies when due and payable in Monroe County New York.

Should it be necessary to assign the account balance to a collection agency or attorney for legal action, the Applicant agrees to pay all collection charges and legal fees incurred by CPG to collect this debt.

I hereby authorize our bank(s) and/or references to release any information necessary to assist CPG in establishing a line of credit.