Application For Credit – Perigee Direct

Name *

First

Last

Title

CEO, Webmaster, etc.

Business Name *

Including DBA or AKA or former name of business.

Incorporation *

Federal I.D.

Desired Credit Line (if known)

Monthly Purchase Estimate (if known)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Email - Billing Inquiries *

Phone

FAX

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.

Upload Additional Documents (optional)

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

Upload any Fact Sheets, Vendor Sheets, etc that will help. (Optional)