Netceed Credit Application

The Undersigned Company is applying for credit with Walker & Associates, Inc., Comstar Supply, Inc. and Multicom, Inc. (hereinafter collectively referred to as "Netceed", or individually as "Netceed Company") and agrees to abide by the standard terms and conditions of each Netceed Company, as applicable.

Company Information

This should be empty:

Legal Entity Name *		DBA (if applicable)
Physical Address *		City *
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL	Zip *
Web Address
Email Invoice *	Yes No	Email Address
Bill to Address *		Bill to City *
Bill to State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL	Zip *
A/P First Name *		A/P Last Name *
A/P Phone *		A/P Email *
Federal Tax ID *		DUNS Number
Business Established *		Number of Employees
Nature of Business		Number of Locations
Publicly Traded	Yes No	Stock Symbol
Prior Bankruptcy	Yes No	Discharge Date		Chapter Filed	7 11 13 15
Incorporated	Yes No	State of Incorporation	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL	Business Type	Sole Proprietorship Corporation Partnership Government Other

Are you a Subsidiary, Division or Affiliate of another company?      Yes    No

Parent Name *		Parent Type *	Subsidiary Division Affiliate
Parent Address *
City *
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL
Zip *

Owners / Partners / Officers

First Name *		Last Name *		Position *
Phone *		Email Address
First Name		Last Name		Position
Phone		Email Address
First Name		Last Name		Position
Phone		Email Address

Authorized Purchaser(s)    

First Name *		Last Name *		P.O. Required *	Yes No
First Name		Last Name		Credit Limit *

Trade References

Company Name *		Phone *		Fax
Address *		City *		Email
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL	Zip *		Contact *
Account # *
Company Name *		Phone *		Fax
Address *		City *		Email
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL	Zip *		Contact *
Account # *
Company Name *		Phone *		Fax
Address *		City *		Email
State *	AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyomingINTERNATIONAL	Zip *		Contact *
Account # *

Taxes

Tax Exempt *

Yes No

Please provide documentation for all states in which your company is tax exempt.   Until such documentation is received, taxes will be charged for all states in which Netceed is registered.

Upload Tax Certificates:

Choose files or drag them here.

Transmitting Documents:
By Email:  
By Fax:  336-731-3089

Signature

Authorized Signature *	Name of Owner, Officer, or Principal	Title *
A typed signature warrants that the information given above, and related financial disclosures, are true and accurate.

Submit Credit Application

By submitting this application, you agree to our terms and conditions of the sale and authorize Netceed to make inquiries into your banking and business/trade references.