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Credit Application

Fill out the form below, print, & fax to (888) 259-5499

Company: ACUMIX, Inc. Office: 805 Harrogate Drive, Harrisburg, PA 17111
Mailing: P.O. Box 6867, Harrisburg, PA 17112-0867 Phone: (717) 540-9738   Fax: (717) 540-1736
Manufacturing: 200 South 18th St., Harrisburg, PA 17104  

PROFILE:
Company Name: Phone:  Fax:
Address:  City:  State: Zip:
E-mail:
Contact  Title:  EIN/Tax ID:
Proprietorship   Partnership  
Corporation 		 Date Formed:  State:
Tax Exempt Certificate Number: Dunn & Brad:
   
KEY PERSONAL:
President: Vice President:
Treasurer: Controller:
BANK REFERENCE:
Bank:   Officer:
 Phone:
Address:  City:  State:
Zip:
BUSINESS REFERENCES:
Company Name:
Address:  City:  State:
Zip:
Phone:  Fax:  E-mail:
Company Name:
Address:  City:  State:
Zip:
Phone:  Fax:  E-mail:
Company Name:
Address:  City:  State:
Zip:
Phone:  Fax:  E-mail:
Company Name:
Address:  City:  State:
Zip:
Phone:  Fax:  E-mail:
Requested Credit: Limit: $ Net 30 days   Applicants Signature:
REASON DECLINED:
APPROVAL: Yes:  No:  Credit Limit: $  
Credit Manager:  Date:
02.13.17 

ACUMIX, Inc.
Mailing | PO Box 6867  | Harrisburg, PA 17112-0867
Sales & Engineering Office | 805 Harrogate Dr  | Harrisburg, PA 17111
Phone: 800-683-2011 (Sales Only)  717-540-9738 | Fax: 419-616-1524 or 630-869-8821| ACUMIX web site: www.acumix.org