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Credit Application

The information requested below is essential to establishing your credit terms. Please read the General Sale Conditions (English) (French) (German) before submitting a credit application. Credit terms are only available to customers placing orders in excess of EUR 5,000.

Required fields are highlighted and marked by an asterisk.

If you prefer, you may print this page or download a credit application for France (in English, 34K PDF), for Germany (in English, 34K PDF) or for the UK (in English, 46K PDF). Then, fax the completed form to the appropriate country:

Germany: +49 (0)89 60822-150
UK: +32 (0)16 35 21 01
Other: +32 (0)16 35 21 01

By completing and sending this form by fax, you confirm that you have read and accept the Elo TouchSystems Privacy Policy

Customer Status

Are you currently working with a sales person?*

Yes No

If Yes, Name:

Company:
Do you have a purchase order pending with Elo?*

Yes No
If Yes, PO #:

Company Information

Company Name*
Address1*
Address2
Address3
City*
Postal Code*
Country*
Phone*
Fax
E-mail Address for Order Confirmation*
Dun & 
Bradstreet #
Anticipated Annual Purchases, in US Dollars*
Name of Finance Director*
Name of Accounts Payable Supervisor*
E-mail Address for Accounts Payable Supervisor*
Business Structure*
(check one)

Individual
Corporation
Partnership
VAT No.
Line of Business*
Date Started*

Credit (Supplier) Reference 1

Name*
Address1*
Address2
Address3
City*
State/Province
Postal Code*
Country*
Phone
Fax

Credit (Supplier) Reference 2

Name*
Address1*
Address2
Address3
City*
State/Province
Postal Code*
Country*
Phone
Fax

Credit (Supplier) Reference 3

Name*
Address1*
Address2
Address3
City*
State/Province
Postal Code*
Country*
Phone
Fax

Bank Information

Name*
Account #*
Officer
Address1*
Address2
Address3
City*
Zip/Postal Code*
Country*
Phone
Fax

Conditions

Submission of this form attests financial responsibility and willingness to pay our invoices in accordance with the following terms: Net 30 days from the date of invoice.

Further, I/we agree should this account be turned over for collections, applicant agrees to pay collection fees and legal fees incurred, in addition to the unpaid balance due to Tyco Electronics Raychem N.V. (Division Elo TouchSystems). The above information is for the purpose of obtaining credit and is warranted to be true. I/we hereby authorize the firm to whom this application is made to investigate the references listed pertaining to my/our credit and financial responsibility.

I have read and I accept the General Sale Conditions. (English) (German)

Name*
Title

I have read and I accept the Elo TouchSystems Privacy Policy:

August 2001