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Securitech International, Inc.
APPLICATION FOR CREDIT
 A Securitech Authorized Dealer must have a credit application on file.  Please answer all questions.  A signed Credit Approval Agreement must also be printed out, signed, and mailed or faxed to us at 407.295.1822.  Incomplete applications will not be processed. 

* Required fields
Name *
E-mail Address *
Company *
Adress *
City *
State *
Zip *
Phone *
Fax Number
Mailing Address (if different from above):
Type of Business * Security Dealer
Fence Dealer
Other
Year Business Started
Years at Present Location
Annual Sales
License #
Type of Organization * Private Corporation
Public Corporation
Partnership
Sole Proprietorship
Officer #1 Name
Officer #1 Title
Officer #1 Home Address
Officer #1 Home Phone
Officer #2 Name
Officer #2 Title
Officer #2 Home Address
Officer #2 Home Phone
Bank Name *
Bank Account Number *
Bank Address *
Bank Phone Number *
Bank Fax Number *
Bank Contact Name/Title
Trade Reference #1 Company Name *
Trade Reference #1 Account Number
Trade Reference #1 Address *
Trade Reference #1 Phone Number *
Trade Reference #1 Fax Number *
Trade Reference #2 Company Name *
Trade Reference #2 Account Number
Trade Reference #2 Address *
Trade Reference #2 Phone Number *
Trade Reference #2 Fax Number *
Trade Reference #3 Company Name *
Trade Reference #3 Account Number
Trade Reference #3 Address *
Trade Reference #3 Phone Number *
Trade Reference #3 Fax Number *
Trade Reference #4 Company Name
Trade Reference #4 Account Number
Trade Reference #4 Address
Trade Reference #4 Phone Number
Trade Reference #4 Fax Number
Credit Limit Requested $
Are You Tax Exempt?** *
Names of persons authorized to place orders

I have read and agree to the Privacy Policy *

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**If you answer yes, you must submit a signed Sales Certificate with your application. Please fax to 407.295.1822. In placing this application for credit, the Customer agrees to pay all invoices within terms granted and to pay a service charge of 2% per month on all past due balances.  In the event a suit is necessary to collect any amount, the Customer agrees to pay the Seller's reasonable attorney fees and costs, including attorney fees for appeal.