Application For Credit – Perigee Direct

Primary Business Name *

Please include legal name.

Additional Business Names (optional) *

Please include additional name used, like DBA, AKA or other former names of business.

Approximate Date Business Started

Please give approximate date when the business was formed.

Legal Structure *

Corporation
LLC
Partnership
Proprietorship

Federal I.D. (FEIN) *

State Tax ID

Desired Credit Line (if known)

Monthly Purchase Estimate (if known)

Billing / AP Information

Primary Billing Name *

First

Last

Title

Finance, Webmaster, CEO, etc.

Additional Billing Names (optional)

List as many people as necessary, separate with a comma

Primary Billing Email *

Additional Billing Emails (optional)

Primary Billing Phone *

Additional Billing Phones (optional)

List as many Phone numbers as necessary, separate with a comma

Billing FAX (if applicable)

Address – Billing *

Address Line 1

Address Line 2

City

State

Zip Code

Shipping Information (initial or first location)

Primary Customer Name *

First

Last

Title

Additional Customer Names (optional)

List as many people as necessary, separate with a comma

Primary Customer Email *

Please include as many billing, finance, AP emails as is applicable, separated by a comma (,)

Additional Customer Emails (optional)

List as many emails as necessary, separate with a comma

Primary Customer Phone *

Additional Customer Phones (optional)

List as many Phone numbers as necessary, separate with a comma

Address – Customer / Shipping / Reciving *

Address Line 1

Address Line 2

City

State

Zip Code

Bank and Trade References

Banking Information

Include Bank, Branch, Address, Phone, Acct Rep/Officer, Routing and Account numbers etc.

Trade References

List as many or as few as you feel is appropriate. please do not list service providers or personal references.

Relevant Officers or Line of Credit Key Stakeholders

Please list the officer names, titles, physical addresses, contact phone numbers, and contact email addresses.

Upload Additional Documents (optional)

Click or drag files to this area to upload. You can upload up to 10 files.

Upload any Prepared Fact Sheets, Credit Memos, Letters, Vendor Sheets, etc that will help.