Memory Solutions (Flash, DDR Memory, DRAM)

Part I. Applicant Information (* indicates required fields)

Credit Request Date:	2012-05-17 08:16:03
Full Legal Business Name: *
Trade Name (DBA):
Type of Business: *
Billing Address: * (No PO Box)
Address Line 2:
City: *
State or Province: *
Zip Code: *
Country: *
Tel Number: *
Fax Number:
Email Address: *
Reenter Email Address: *
If different from billing address
Shipping Address: (No PO Box)
Address Line 2:
City:
State or Province:
Zip Code:
Country:

Part II. Principal Owners, Officers and Partners (* indicates required fields)

Name: *
Title: *
In Position since:
Name: *
Title: *
In Position since:
Business Type:
State Incorporated in:
Retail Tax #: * (Please provide signed copy)
D&B Number: *
Federal Tax ID #: *
Buyer Name: *
Tel Number: *
Fax Number:
Email Address: *
A/P Contact Person: *
Tel Number: *
Fax Number:
Email Address: *

Part III. Acknowledgement

Applicant hereby authorizes the release of all pertinent information necessary to Unigen Corporation for processing the applicant's request for credit, including bank record, trade references and other financial data. Unigen Corporation reserves the right to decline credit and/or change/revoke Applicant’s credit limit on the basis of changes in Unigen Corporation’s credit policies or Applicant’s financial condition and/or payment record. All sales of products and services by Unigen Corporation to Applicant will be subject to Unigen Corporation’s standard Sales Terms and Conditions and the Warranty Return Policy which is in effect at the time of order. A faxed and signed copy of this document shall bind the Applicant applying for credit on this original document.

Applicant(s) agrees to pay all money due promptly in accordance with the payment terms indicated on Unigen Corporation invoices. In Event of default or unpaid invoices all invoices all invoices shall bear interest at an amount equal to 1.5% per month commencing on the date payment due until funds verified by Unigen Corporation’s bank. Should Applicant default on terms and legal action become necessary, applicants agrees pay all related collection expenses including administrative costs and attorney’s fees. The law of the State of California shall govern all contracts entered into between Applicant and Unigen Corporation that all disputes may be resolved within the Courts within the State of California.

The information submitted is warranted to be true and correct.
Authorized Signature: *
On Behalf of: *
Your Name: *
Title: *
Date: *
Customer Comments: