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Section 1: Company Information |
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Applicant (Company) Name: |
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| DBA: |
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| Street Address: |
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State: |
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Zip Code: |
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| Tel: |
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Fax: |
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Month and Year Business Started:
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U.S. State of Incorporation |
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Federal Tax ID Number: |
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OFFICERS, OWNERS or BOARD OF DIRECTORS |
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Name:
Title:
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Name:
Title:
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Name:
Title:
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CREDIT INFORMATION |
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Purchasing Contact Name: |
Phone:
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A/P Contact Name: |
Phone:
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Amount of Credit Requested:
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Section 2: Seller's Permit |
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Please fax Covid, Inc. a copy of your
seller’s permit. If you are unable to submit a copy of your seller’s
permit, please complete and return the following information: |
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On Behalf of the Applicant, the undersigned
hereby certifies: That the Applicant (Company) listed above holds a
valid Seller’s Permit, with the following information: |
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Permit No.: |
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Selling: |
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The undersigned further certifies that the
tangible personal property described herein which will be purchased from
Covid, Inc. will be resold by the Applicant in the form of tangible
personal property. It is understood that the Applicant is required by
the State and Use Tax Laws to report and pay tax. Such tax is measured
by the purchase price of such property regardless of use of the
purchased product. |
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Applicant (Company) Name: |
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Authorized Signature on Behalf of Applicant |
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By completing this field with
your name, it is considered a signature |
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Printed Name: |
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Title: |
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Date: |
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Applicant Address: |
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City: |
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State |
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Zip Code: |
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Tel: |
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Fax: |
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Email: |
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Section 3: References |
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Financial Institutional Reference |
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Bank or Credit Union Name: |
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Contact Name: |
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Account Number : |
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Address: |
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City |
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State |
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Zip Code: |
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Tel: |
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Fax: |
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Trade References |
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1. Company Name: |
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Contact Name: |
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Account Number : |
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Address: |
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City |
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State |
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Zip Code: |
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Tel: |
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Fax: |
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2. Company Name: |
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Contact Name: |
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Account Number : |
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Address: |
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City |
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State |
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Zip Code: |
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Tel: |
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Fax: |
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3. Company Name: |
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Contact Name: |
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Account Number : |
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Address: |
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City |
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State |
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Zip Code: |
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Tel: |
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Fax: |
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4. Company Name: |
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Contact Name: |
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Account Number : |
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Address: |
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City |
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State |
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Zip Code: |
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Tel: |
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Fax: |
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| The undersigned
is authorized to release the required Credit Application information.
The undersigned is further approved on behalf of the Applicant to
request release of credit reference information to Covid, Inc. in order
to obtain Covid Credit Approval. Covid, Inc. cannot process Credit
Applications until all information has been fully disclosed. |
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By completing this field with
your name, it is considered a signature |
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Your Email Address |
Date Submitted |
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| By clicking
on submit, you are agreeing to Covid's Terms and Conditions |
| To read the
terms and conditions, click
here - it will open a separate window, and your form will not be
affected. |
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