Credit App - INPAX

Company Profile

Legal Business Name(Required)

Trade Name (DBA if applicable)

Company Contact(Required)

First Last

Email(Required)

Phone(Required)

Website

Credit Request Amount(Required)

Requested Terms(Required)

Credit Letter (if applicable)

Drop files here or

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 64 MB, Max. files: 2.

If you already have a Credit Reference and upload it here, then you can skip the section requiring that information.

Billing Address (not required if Credit Letter is uploaded containing this information)

Street Address Suite/Unit City State ZIP Code

A/P Contact

First Last

A/P Email(Required)

A/P Phone(Required)

Purchasing Agent

First Last

Email

Phone

Company Info

Company Type

State of Registration

State

Federal ID (EIN)(Required)

Are you a subsidiary?

Yes

No

W-9(Required)

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

Upload your W-9.

Years in Business

Number of Employees

Ownership Info (no required if on uploaded documents)

Owner #1

First Last

Title / Role

Ownership Percentage 1

Email

Phone

Owner #2 (If Applicable)

First Last

Title / Role

Ownership Percentage

Email

Phone

Owner #3 (If Applicable)

First Last

Title / Role

Ownership Percentage

Email

Phone

Trade References (if applicable)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 64 MB.

If you upload your trade reference letter, then you will not need to complete the below references.

Trade Requests (not required if on uploaded documents)

In order to timely process your application and improve trade reference responses, we ask that you notify your trade reference that they will be receiving a reference request.

Business Reference #1

Contact Name

First Last

Email

Phone

Business Reference #2

Contact Name

First Last

Email

Phone

Business Reference #3

Contact Name

First Last

Email

Phone

Bank Information (not required if ACH Form and Voided Check are uploaded)

ACH Form and Voided check (if applicable)

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 64 MB, Max. files: 2.

Bank Name

Account Number

Bank Contact Name

First Last

Bank Contact Email

Bank Contact Phone

Bank Authorization Consent(Required)

By checking this box, you agree and certify that by typing your name below it is your intent to sign this authorization and that the below electronic signature shall have the same force and effect as a manual signature

Bank Authorization
We are authorizing _________ to release information about our account ending in _____, any outstanding credit line and payment history to INPAX, to be used to establish an account and credit line. This information is to be kept in strict confidence.
By checking this box, you agree and certify that by typing your name below it is your intent to sign this authorization and that the below electronic signature shall have the same force and effect as a manual signature

Name(Required)

Title(Required)

Date(Required)

Review + Submit

Thank you for taking the time to complete this credit application. Please review the terms and conditions below before e-signing and submitting your application for review

Consent(Required)

By checking this box, you agree and certify that by typing your name below it is your intent to sign, authenticate, and adopt this document and that the below electronic signature is valid and legally binding and shall have the same force and effect as a manual signature.

The information given herein is offered as part of a request by the applicant for an extension of credit for commercial business use. The information provided is represented by the applicants to be true, correct, and complete. The Applicant authorizes Creditor to investigate all credit references and other sources pertaining to our credit and financial responsibility. The undersigned authorizes its banks and trade creditors to provide Creditor with complete information for the purpose of credit evaluation. The applicant understands that all past due balances will be subject to a ______ per month finance charge. The applicant further agrees to pay all collection costs in the event of default if the account is placed with a collection agency

Name(Required)

First Last

Date(Required)