LabCommerce, Inc.
Confidential Credit Application
To establish an account with LabCommerce, Inc., please print the following credit applicationand mail it to:
LabCommerce, Inc.
P.O. Box 4144
San Jose, CA 95150, U.S. A.

Note: For security purposes, we recommend that your confidential
information not be transmitted via e-mail.

Bill to Address Shown Below:
Company:

Ship to Address Shown Below:
Company:

Street Address:

Street Address:

City/State/Zip:

City/State/Zip:

Contact Person:

Contact Person:

Tel. No.:

Tel. No.:

Email Address:

Email Address:

Bank Reference
Name of Bank:

Branch Location:

Street Address:

Checking Account Number:

City/State/Zip:

Loan Number:Contact Person:

Type of Loan:

Tel. No.:Fax No.:Email Address:

Email Address:

LabCommerce Confidential Credit Application

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Trade References [Please complete all four (4) boxes below.]
Company:
Company:
Street Address:

Street Address:

City/State/Zip:

City/State/Zip:

Contact Person:

Contact Person:

Tel. No.:

Tel. No.:

Email Address

Email Address:

Trade References (continued)
Company:

Company:

Street Address:

Street Address:

City/State/Zip:

City/State/Zip:

Contact Person:

Contact Person:

Tel. No.:

Tel. No.:

Email Address:

Email Address:

The undersigned hereby grants authority and directs the financial institutions(s) andtrade creditors above to release all information requested by LabCommerce.

Signature (owner/officer)
Print Name:
Date:========================================================================
Company Information
Number of employees:
D&B number:

SIC code:Type of Business:
D&B rating:Taxpayer I.D.:
How much credit are you requesting?

LabCommerce Confidential Credit Application

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Resale Information
Are you purchasing for resale?

If you answered yes, you must provide us

with a completed and signed resale certificate; otherwise, you will be charged sales tax.
Names of Officers, Partners or Owners
Name:
Title:
Street Address:
City/State/Zip:
Agreement
It is understood and accepted by the undersigned officer or owner that:
1. All invoices are due and payable on a net 30-day, date-of-invoice basis, unlessotherwise agreed to in writing.
2. In the event suit is required to enforce collection of unpaid balances, customer agrees topay reasonable collection and /or attorney fees and all court costs.
3. A facsimile copy of this document is to have the same force and effect as an original.
4. Any amounts not paid within terms may be subject to a late charge of 1-1/2% per month,
APR 18%. The undersigned certifies that they are owner or officer of the company,
familiar with its financial status and records and fully authorized to sign this agreement.

Signature:
Title (must be an owner or officer of the company):
Print Name:
NOTE:
If you have a preprinted list of bank and trade references you may attach it to this application;
however, please complete all other information and sign in the appropriate two places.
Return completed Credit Application with original signatures on the two signature pages
to:Attention: Accounting
LabCommerce, Inc.
P.O. Box 4144, San Jose, CA 95150, U.S.A.

For questions or comments, please contact us at:
LabCommerce, Inc.™
Phone (408) 265-6482 | meriter@mindspring.com

LabCommerce Confidential Credit Application

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