VK01
Date:
Company’s Legal Business Name:
Number of Years in Business:
Sales Contact’s Name:
Sales Address:
Sales Telephone (Extension):
Sales Fax Number:
Sales E-mail Address:
Accounting Contact’s Name:
Accounting Remit To Address:
Accounting Telephone (Extension):
Accounting Fax Number:
Accounting E-mail Address:
Country:
Federal Tax ID Number (For U.S. Vendors Only):
Account Number Assigned to Velocity Electronics:
Banking Information (If Terms Are TTA): Bank Name and Branch:
Bank Address:
Beneficiary Name:
SWIFT Code*:
Bank Key*:
Your Account Number:
Did You Receive Our Bank & Trade, Insurance Binder, and Resale Certificate: YES / NO
Payment Terms Extended To Velocity Electronics
[NET 30, TTA, COD, Escrow, CCA (American Express), CCV (Visa)]:
Signature authorizing the above payment terms
(does not have to be signed if terms are COD or Escrow):
*SWIFT – Society for Worldwide Interbank Financial Telecommunication
*Bank Key – Specify the Bank Key under which your bank data from the respective country is stored.
Below Is For Velocity Electronics Use Only
Velocity Electronics Acct Mgr’s Name: Matthew Rubino
Acct Mgr - Is this a franchise distributor? Yes / No
Accounting Depart Approval Decision: Yes / No
Approved By (Name, Signature, and Date):