MARYLAND METRICS

Credit Application by E-mail

Please use this form if you would like to submit a credit application via e-mail.

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Please complete the form below with enough information to assure accurate processing of the credit application. When finished press the 'SEND' button.

* OPTIONAL RESPONSE

COMPANY NAME:
SHIPPING ADDRESS:
2nd SHIP ADD. LINE:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EXTENSION NO.:
FAX NUMBER:
E-MAIL ADDRESS:

BILLING NAME and ADDRESS IF DIFFERENT THAN ABOVE:
(You may omit any information below which is duplicated in the above section.)

COMPANY NAME:
BILLING ADDRESS:
2nd BILL ADD. LINE:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EXTENSION NO.:
FAX NUMBER:
E-MAIL ADDRESS:
Into what business category would organization fit?


***If you selected 'DISTRIBUTOR above, then click on the appropriate product groups below. You may select more than one product group by holding down the 'ctrl' key while clicking.

BANK NAME:
ACCOUNT NUMBER (must have):
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EXTENSION NO.:
FAX NUMBER:

REF. No. 1 COMPANY NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EXTENSION NO.:
FAX NUMBER:

REF. No. 2 COMPANY NAME:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER:
EXTENSION NO.:
FAX NUMBER:

I hereby authorize Maryland Metrics to request credit information from the above listed banks and trade credit references.
FIRST NAME:
LAST NAME:
TITLE :

Please enter any comments or specific requests here:

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