Credit Application

AC Miller Credit Application

Your sensitive data is safe with us, AC Miller employs 256 bit encryption technology on our website (PKCS #1 SHA-256 With RSA Encryption). This is the highest form of encryption that is available. In order to to retrieve the data, after the form is submitted, we login to a secured area. We do not store this information for more than 30 days. Also, we are running; Malware Remediation, Linux Security Bundle, ThreatStack: Fully Managed Intrusion Detection System (Dedicated Servers) , and Vulnerability scanning and assessment for Linux.

Step 1 of 5

D&B Information:

Listed by Dun & Bradstreet:(Required)

Yes

D&B Number

Rating

Bank Information:

Bank Reference Information (Name of Bank):(Required)

Bank Reference Information (Bank Address):(Required)

Street Address Address Line 2 City State ZIP Code

Bank Reference Information (Phone number):(Required)

Bank Account Number(Required)

Type of Bank Account:(Required)

Contact Person:(Required)

First Last

Trade References:

1) Trade Reference Name:(Required)

Phone:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Years dealing with this company:(Required)

Items Purchased:(Required)

Terms/Credit Limit:(Required)

2) Trade Reference Name:

Phone:

Address

Street Address Address Line 2 City State ZIP Code

Years dealing with this company:

Items Purchased:

Terms/Credit Limit:

3) Trade Reference Name:

Phone:

Address

Street Address Address Line 2 City State ZIP Code

Years dealing with this company:

Items Purchased:

Terms/Credit Limit:

Bonding Agent or Broker:

Bond Agent or Broker Name:(Required)

Contact Person:(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Dealing Since:(Required)

Bonding Limit:(Required)

Equipment Loans/Leases:

Name of Financial Firm:

Financial Statement Available?

Yes

Upon Request

Address of Firm:

Street Address Address Line 2 City State ZIP Code

Terms: NET 30 DAYS, or previously agreed upon terms with AC Miller Corp., from invoice date. AC Miller reserves the right to impose a 1.5% (18% APR) finance charge and the right to withhold future shipments if the account balance becomes past due (aged over 30 days or previously agreed upon terms with AC Miller Corp.). If outside collection becomes necessary, the buyer agrees to pay all collection costs plus reasonable attorneys fees. Please see AC Miller Corp. Terms and Conditions click here.

Tax Exempt Certificate:

Max. file size: 50 MB.

Please provide a sales tax exempt certificate if applicable - tax will be charged unless completed certificate is provided.

Signature(Required)

This field is for validation purposes and should be left unchanged.

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AC Miller Credit Application

Company Information

D&B Information:

Bank Information:

Trade References:

Bonding Agent or Broker:

Equipment Loans/Leases:

Contact information

Locations:

Contact

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Credit Application

AC Miller Credit Application

Company Information

D&B Information:

Bank Information:

Trade References:

Bonding Agent or Broker:

Equipment Loans/Leases: