Infomercial Monitoring Service, Inc.

Credit Application

Please fill out and print this form, then FAX it to IMS at 610-328-6791, or you can send it electronically by hitting the submit button when you've completed the form.

Contact Information

Billing Information

Contact Name		AP Contact Name
Company Name		AP Company Name
Address		Address
Phone		Phone
Fax		Fax
E-mail		E-mail

General Company Information


Federal Tax ID #		Principal Officer
Dunn & Bradstreet #		Title

Legal Structure (check all that apply)

In Business Since

Business Type

Bank References

Bank Name		Bank Account #
Address		Bank City/State/Zip
Bank Contact		Bank Account Type

Reference Companies

Contact Person

Phone Number

Credit Card Information

Name on Credit Card

Credit Card #

Expiration Date

Electronic Signature and Authorization

The electronic signature below represents and warrants that (a) the party signing below is an authorized representative of the company, (b) the information provided herein is a complete and accurate representation of the company's financial situation as of the date hereof, and (c) work performed will be charged on the company's credit card for any outstanding balance more than thirty (30) days overdue.

Electronic Signature

E-Signature

Title

	Corporation	LLC	Sole Proprietor
	Partnership	LLP	Non-Profit