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FAX Credit Application Form

Please print out this form, fill out completely and fax to IMTEK at:
(770) 667-8683.

Name_____________________________________________ Title_____________________________________
Company__________________________________________ Address___________________________________
City_____________________________________________ State_____________________________________ 
Zip______________________________________________ Country___________________________________ 
Phone____________________________________________ FAX_______________________________________ 
E-mail___________________________________________

PRINCIPALS (if corporation, list officers, if partnership, list partners)


1. Name_________________________________________ Title_____________________________________________ 
 Home Address_________________________________ City______________________________________________ 
 State________________________________________ Zip_______________________________________________ 
 Country______________________________________ Phone_____________________________________________

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2. Name_________________________________________ Title_____________________________________________ 
 Home Address_________________________________ City______________________________________________ 
 State________________________________________ Zip_______________________________________________ 
 Country______________________________________ Phone_____________________________________________

---------

3. Name_________________________________________ Title_____________________________________________ 
 Home Address_________________________________ City______________________________________________ 
 State________________________________________ Zip_______________________________________________ 
 Country______________________________________ Phone_____________________________________________

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SALES TAX STATUS (Please check one)

Not Tax Exempt____ Tax Exempt ____ Tax Exempt Number__________________

BANK REFERENCE

Bank Officer________________________________________ Bank Name_______________________________________________ 
Address_____________________________________________ City____________________________________________________ 
State_______________________________________________ Zip_____________________________________________________ 
Country_____________________________________________ Phone___________________________________________________ 
Account #___________________________________________

TRADE REFERENCES

1. Contact Name_________________________________________________ 
 Company______________________________________________________ 
 Address______________________________________________________ 
 City_________________________________________________________ 
 State________________________________________________________ 
 Zip_________________________________________________________ 
 Country______________________________________________________ 
 Phone________________________________________________________

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2. Contact Name_________________________________________________ 
 Company______________________________________________________ 
 Address______________________________________________________ 
 City_________________________________________________________ 
 State________________________________________________________ 
 Zip_________________________________________________________ 
 Country______________________________________________________ 
 Phone________________________________________________________

----------

3. Contact Name_________________________________________________ 
 Company______________________________________________________ 
 Address______________________________________________________ 
 City_________________________________________________________ 
 State________________________________________________________ 
 Zip_________________________________________________________ 
 Country______________________________________________________ 
 Phone________________________________________________________

BUSINESS INFORMATION

Individual ____ Partnership ____ Corporation ____
Type of Business______________________________ Number of Employees__________________________ 
Years in Business_____________________________ Annual Sales $_______________________________ 
D+B Listed? Yes____ No____ Amount of Credit Requested $ ______________________

BY COMPLETING THIS APPLICATION FOR CREDIT, THE APPLICANT:

1. Attests financial responsibility, ability and willingness to pay all invoices
in accordance with the following terms: 2% 10; Net, 30 days, service charges will be
paid at the rate of 1.5% (18% annual rate) on all balances over 30 days.

2. Hereby Authorizes IMTEK ENVIRONMENTAL CORP. to investigate
the references listed pertaining to the applicant's credit and financial responsibility and
obtain additional information by securing data from a credit reporting agency.

3. Hereby Agrees that should it become necessary to assign the applicant's
account to a licensed collection agency or atttorney for legal action, all subsequent
collection charges and legal fees shall be paid by the applicant.

4. Hereby Authorizes the seller, its successors and assigns, by the seller's
designated attorney to waive the issuance of process and confess judgment against the
applicant for the entire unpaid balance of applicant's account together with all costs
applicable to such action.

5. Certifies and Warrants that the information given in this application is true and
correct and is given for the purpose of obtaining credit.

Applicant Name__________________________________ Position____________________________________
Date________________ 
Applicant Name___________________________________ Position____________________________________ 
Date________________ 
 
 
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