Credit Application           Please Print & Fax To:  214-904-0983

D&B #

Registered Company Name

Operating As

Address

Phone

Fax

Contact

Start Of Business Date

Invoicing Address

Phone

Fax

A/P Contact

Terms

Principal, Partners or Officers:   Name / Title

Millennium Charges and remits all applicable taxes unless provided with Hardcopy Tax Exemption Certificates.     Are Certificates Attached?       YES          NO          (Circle One)

Trade References (of more than 1 year)     Name / Address / Phone

Banking Information

Bank

Address

Phone

Fax

Account #

We hereby authorize the release of credit to Millennium Midrange Systems

Signature / Title