CUSTOMER INFORMATION & CREDIT STATUS FORM

COMPANY NAME :

OFFICE ADDRESS :

STORE ADDRESS :

WAREHOUSE ADDRESS :

TEL. NO. :
FAX NO. :

Type of Business Single Proprietorship Partnership Corporation Other

Principal Business Importing Retail Manufacturing

Activities Distributing Wholesaling Others

CREDIT REFERENCES: ADDRESS TEL. NO. TERMS

1.

2.

3.

BANK REFERENCES: ADDRESS TEL NO. TERMS

1.

2.
_
3.

PERSON/S AUTHORIZED TO PLACE ORDER/POSITION EMAIL AND CONTACT NUMBER

1.

2.

PERSON/S AUTHORIZED TO RECEIVE ORDERS EMAIL AND CONTACT NUMBER

1.

2.

CONTACT PERSON/S FOR COLLECTION TELEPHONE NUMBER

 DECLARATION

I hereby certify that all particulars given/mentioned in this form are the truth to the best of my
knowledge and authority. This declaration shall constitute an integral part of my contract and
services being offered by Quartz Business Products Corporation to the above mentioned
Company/Establishment which is duly represented by the undersigned.

Residence Certificate No.

Signature over Printed Name

Place of issue
Position//Designation
Date of issue

Please submit photocopies of the ff:

Business Name of Registration
DTI or SEC Permit
Current Years Mayor’s Permit

TO BE FILLED UP BY QUARTZ BUSINESS PRODUCTS CORPORATION

APPROVED CREDIT TERMS : CONFORME:

APPROVED CREDIT LIMIT :

APPROVED BY: QUARTZ BUSINESS PRODUCTS CORPORATION

AUTHORIZED SIGNATURE

POSITION / DESIGNATION

DATE OF EFFECTIVITY