ATX Case, Computer Cases, PC Cases, Custom Computer Cases, Cool Computer Cases at ATXCases.com

ATXCases, Inc.
Whole Sale Computer Cases, Power Supplies and More!

*Background Information ( fields are required)**		Referral
*Name of Applicant:			Referrer:
Position of Applicant:
*Legal Business Name:			Banking Information
DBA:			Banking Information
*Tax ID or SS Number:			Bank Name:
*Mailing Address:			Location:
Address Line 2:			Phone:	()--
*City:			Fax:	()--
*Select Your County:			Contact Person:
*Select Your State:			(You can enter this infomation in the fields below OR fax us a copy of a voided check here 1-904-730-9525 )
*ZipCode
*Phone:	()--		Account Number:
Fax:	()--		Routing Number:
*Email Address:
Website URL:
Years In Business:			Trade History
Number of Employees:			Company 1:
Estimated Annual Volume:			Location:
Business Type:			Phone:	()--
			Fax:	()--
Owners / Partners			Contact Person:
1st Partner Full Name:
Email Address:			Company 2:
Phone:	()--		Location:
Extension:			Phone:	()--
			Fax:	()--
2nd Partner Full Name:			Contact Person:
Email Address:
Phone:	()--
Extension:			Company 3:
			Location:
3rd Partner Full Name:			Phone:	()--
Email Address:			Fax:	()--
Phone:	()--		Contact Person:
Extension:
Release of Information: I/We expressly consent to the Prine Systems Inc. obtaining any reports containing credit of personal information required in obtaining credit from the Prine Systems Inc. I/We declare that the information given on this application is true and accurate to the best of my/our knowledge. This declaration is made for the purpose of obtaining credit from the Prine Systems Inc. and will remain confidential. I have read and agreed to the Release of Information. Signature of the person submiting this information: ( Your Full Name )