MEDIUS CORPORATION
Credit Application

Please take a moment to request a credit line with Medius. If you prefer, you may print this application and fax the information to our Accounting Department at (408) 519-5001. All information submitted is held strictly confidential and is governed by our Safe Harbor Certification.

Company Name:
DBA (if different):
A/P Contact Person:
Address 1:
Address 2:
City
State:
ZIP/Postal Code:
Phone:
Fax:
Federal Tax ID Number:
Amount of Credit Requested: $
 
Corporate Information
State of Incorporation:
Name/Address of Residential Agent:
Type of Business:
Date Business Established: (MM/DD/YYYY)
Are you sales tax exempt? Yes No
Have you ever had credit with us before? Yes No
Names and Titles of your Authorized Purchasers:
Purchase Order Required? Yes No
 
Trade Reference #1
Company Name:
Address 1:
Address 2:
City:
State:
ZIP/Postal Code:
Phone:
 
Trade Reference #2
Company Name:
Address 1:
Address 2:
City:
State:
ZIP/Postal Code:
Phone:
 
Trade Reference #3
Company Name:
Address 1:
Address 2:
City:
State:
ZIP/Postal Code:
Phone:
 
Bank Reference #1
Account Number:
Name of Bank:
Contact Person:
Phone:
Address 1:
Address 2:
City:
State:
ZIP/Postal Code:
 
Bank Reference #2
Account Number:
Name of Bank:
Contact Person:
Phone:
Address 1:
Address 2:
City:
State:
ZIP/Postal Code:
 
By checking this box you agree to the following:

I represent that the above information is true and accurate and is given for the purpose of obtaining credit from Medius. My company and I authorize Medius to make such credit investigation, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to Medius any and all information concerning the financial and credit history of my company. This application and agreement, and all transactions pursuant hereto, are and shall be governed by the Internal Laws of the State of California.
 
Name:
Title: