Application For Credit - Browncor
(a division of ICM Corporation)
Note: This is not an electronic form.
It must be printed out, filled out completely and faxed back
to our office at 1-800-343-9228.

Directions: Please fill out all lines completely.
Print out the Form once you have completed the application.
SIGN the form in the Authorization Area below.
FAX the form back to us at the number below.

1. Information Needed to Set Up Your Account Please fill out all lines completely

Date // Anticipated Purchase and/or Amount of Item
$.
Your E-Mail Address
@

Is Your Organization Sales Tax Exempt?

Yes  No

If Yes, Please fax your Sales Tax Exempt Certificate to us with this form.
Application Submitted By:
Name

Title
Is Purchase Order Required? 

 Yes  No

P.O.#

Business Fax Number
()-
Business Phone Number
()-
Person to Contact Re: Account
Full Legal Name/Business Entity

Doing Business As:

Street Address

City

State/Country (abbrev. ok)                   Zip Code + 4
               -

Number of Employees
1-4  5-9   10-19  20-49   50-99   100+

Annual Sales
$

Dun & Bradstreet#

Number of Business Locations
        Since


Billing Street Address (if different than above)

City

State/Country (abbrev. ok)

Zip Code + 4
-

If Subsidiary, Name of Parent Company, Address, City, State, Zip


Business Type
(please check one)
82Education/Schools 20Manufacturing/Printing
80Medical/Health 91Government 40Transportation/
      Communications/Utilities
87Engineering/
      Architecture/Consulting
50Wholesale Trade 15Construction/
     Contractors
63Insurance 65Real Estate 52Retail Stores/Restaurants
99Other
2. References for Your Business
Bank Reference #1: Bank Name and Address Line

City & State

Zip Code + 4 -                     Phone Number ()-
Contact Person

Checking Account #

Bank Reference #2: Bank Name and Address

City & State

Zip Code + 4 -                     Phone Number ()-
Contact Person

Checking Account #


Trade Reference #1 Name

Account #
Phone Number
()-
Fax Number
()-

Trade Reference #2  Name
Account #
Phone Number
()-
Fax Number
()-

Trade Reference #3  Name
Account #
Phone Number
()-
Fax Number
()-

3. Authorization Is Required

a. Check here if Incorporated for more than one year and type the Principle's Name Below. If you have not been incorporated for more than one year, please refer to section 3b. below. 
Company Principle's Name & Title  

b. Check here if Incorporated for less than one year, a sole proprietorship, or a partnership and enter Principle's Name Below.
Company Principle's Name & Title  

Personal Credit Information / Guarantee
(Must be completed by a corporation in business less than one year, an unincorporated business, a sole proprietorship, or a partnership)
I agree that if my business has been incorporated for less than one year, is unincorporated, a sole proprietorship, or a partnership, I authorize BrownCor or its' agent to investigate my personal credit financial records, including banking records. It is understood that my personal credit bureau report may be requested by the company to assist in the investigation of my financial records and I personally guarantee the repayment of the debt. If my business has been incorporated for one year or more, it is understood that my personal financial records will not be investigated without my prior authorization.

Company Principle's First Name
Initial
Last Name
Social Security No.
--
Present Home Address (Number & Street)
Home Phone Number
()-
City
State
Zip Code

BrownCor is herewith submitted for the purpose of opening an account. By submitting this form, I hereby certify all  information to be true and accurate. All information provided will be used by BrownCor employees to determine credit worthiness and/or effect collections. Applicant agrees to pay any collection fees incurred to collect the balances owed including reasonable attorney's fees. BrownCor  reserves the right to assess an interest charge of 1.5% per month (18% annually) on all invoices over 30 days old.


Signature Authorizing Credit Verification and Processing for Credit Approval

Sign the authorization line below and fax back this completed form for Credit Approval. Time is of the essence in returning the faxed signature form and Credit will not be issued without receipt of authorized signature. 

Principle or Authorized Signature (Company owner/principle will be held liable for all purchases regardless of party signing credit application, and balances owed are non-transferrable and non-assignable to other parties for any reason.)

Signed________________________________________________________________________Date________________________


Fax Signed and Completed Form to us Toll Free: 1-800-343-9228

Order Toll Free 
1-800-327-2278

www.browncor.com

In Wisconsin Call:
414-290-1075


Copyright 2008 by BrownCor, All Rights Reserved.