Retail Wholesale Directs Destination
 
 
 
This credit application is to be completed by an authorized individual of the business submitting the application.
 
COMPANY DETAILS
 
City State Zip
Contact
Email Phone
Fax Web
Type of Business
   
In Business Since Registraion No:
 
BANK REFERENCES (at least one)
Bank
Branch Account
Contact Person
 
Phone Fax
Address
 
City State Zip
Country
 
 
Bank
Branch Account
Contact Person
 
Phone Fax
Address
 
City State Zip
Country
 
CREDIT REFERENCES
Company Contact person: Phone: E-mail:
Address: City: Zip: Country:
 
       
Company: Contact person: Phone: E-mail:
Address: City: Zip: Country:
 
       
Company: Contact person: Phone: E-mail:
Address: City: Zip: Country:
 
CUSTOMER AUTHORIZATION

Customer authorizes Excila Telecom and its designee to investigate customer credit worthiness. It is understood that Excila Telecom will retain this application whether or not it is approved. All information will be held in the strictest confidence.