Dynacorn - Customer Account Application

4030 Via Pescador, Camarillo, California 93012
Tel: (805) 987-8188 Fax: (805) 388-0786

Customer Account Application

Company Name

Company name is required.

Full Mailing Address

Full Mailing Address is required.

Full Shipping Address (If same, leave blank)

Telephone #

Fax #

Business Class

Corporation

Partnership

Individual

LLC

Years in Business

Est. Annual Purchases From Dynacorn

Banking Information

Bank Name

Account #

Bank Branch

Bank Phone

Trade References

1) Reference Name

Telephone #

Fax #

2) Reference Name

Telephone #

Fax #

3) Reference Name

Telephone #

Fax #

Contact Information

Company Web Sites

Company Email (Shipping confirmation purposes)

Authorized Purchaser(s)

Name

Extension or Direct Phone #

Fax #

Name

Extension or Direct Phone #

Fax #

Terms

C.O.D.

Prepaid

Net 30

Net 10th

Accounts Receivable

Name

Extension or Direct Phone #

Fax #

Agreement & Signature

Failure to comply with the credit terms could result in termination of disruption of service to you. Dynacorn reserves the right to charge 1.5% of the unpaid balance in the case of an account going into 60-90 days delinquency. In the event that a delinquency account is placed with a licensed collector for collection, the applicant agrees to pay the amount of the delinquent account, interest and the collection fees equal to 33 1/3% of the delinquent account. Signing this credit agreement gives Dynacorn International Inc. authority to reference any banking information acknowledged above. Applicant certifies that the above information is accurate and current as of the signed date below.

Authorized Signature:

Signature is required.

Print Name

Date

No account is considered for a Net Terms until having been a Dii customer in good standing for a minimum of one year.