WELCOME to Lafayette Electronic Supply

WELCOME to the website of Lafayette Electronic Supply

Thursday, 20 November 2008 -- 06:37pm CST

Application for Credit

Instructions:
Complete the online application form below. After you press the SUBMIT button, you will be able to print out a copy of the application and fax it to us.

Company Information

Company Name:
Contact E-mail:
Contact Phone:
Contact Fax:
Line of Business or Profession:
# of Employees:
Years Established:

Billing Address

Address:

City:
State/Province:
Postal Code:
Country:

Company Ownership

Type(required):	Individual Partnership Corporation
Principals (Name, Title):

Credit References (Please furnish complete information)

#1 - Company Name:
Address:
City, State, Zip:
Phone:
Fax:

#2 - Company Name:
Address:
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Phone:
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#3 - Company Name:
Address:
City, State, Zip:
Phone:
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#4 - Company Name:
Address:
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Phone:
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Bank References (Please furnish complete information)

Bank Name:
Address:
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Contact:
Account #:
Phone:
Fax:

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Lafayette Electronic Supply • 405 - B North Earl Ave. • P.O. Box 4549
Lafayette, Indiana 47903-4549
Phone 765-447-9660 • Toll Free 800-842-1527 • Fax 765-447-6967
Email sales@lafayetteelectronicsupply.com