Credit Application
NEC AMERICA, INC.
GLENPOINTE CENTRE EAST - 7TH FLOOR
300 FRANK W. BURR BLVD.
TEANECK, NJ 07666
Tel: (877) NEC-FINANCE · (201) 287-8300
Fax: 800-451-5360
EXISTING CUSTOMER YES o NO o If yes, Account # FINANCIAL STATEMENTS MAY BE REQUIRED
SUPPLIER INFORMATION
Supplier Name
Address
Sales Rep Name
Telephone ( )
Fax ( )
EQUIPMENT DESCRIPTION:
Voice Mail/Other:
LEASE INFORMATION
Lease Type (Circle one):
FMV Purchase Option
$1 Purchase Option
Purchase Option______%
Lease Term (Circle one):
24
36
48
60
72
Other
Equipment Cost $___________________ Non-NEC Equipment $________________________ Sales Tax $_____________________ TOTAL $
Estimated Installation Date:______________ Contact:___________________________ Lease Signer:_______________________________ Title:
Lease Rate Factor___________________ Rental Amount_____________________ Number of Advance Rentals_________________ Security Deposit
CUSTOMER INFORMATION
Complete Customer Name
Telephone Number
Fax Number
Trade Style/DBA
Nature of Business
Federal Tax ID#
Headquarters Address
City
State
Zip Code
Installation Address (if different from above address)
City
State
Zip Code
(Circle one):
Corporation
Proprietorship
General Partnership
Limited Partnership
Limited Liability (Company / Partnership)
Not for Profit
Partnership
State or Local Government
Business Start Date:
Bankruptcy History (Circle one): No Yes/When:

Parent Company (if applicable)
Premises (Circle one):
Own
Rent
Name:
Mortgagee/Landlord/Owner:
Address:
Address:
City, State, Zip:
Contact: _________________________________ Phone No.:
Principal/Owner/Partner/Officer
Title
# of years
Social Security #
in this line
of business
Home Address
City
State
Zip
¨ Own
# of years
Home Phone
¨ Rent
at this
address
( )
Principal/Owner/Partner/Officer
Title
# of years
Social Security #
in this line
of business
Home Address
City
State
Zip
¨ Own
# of years
Home Phone(
¨ Rent
at this
address
( )
Name of Bank / Branch
How Long
Contact Name
Telephone
Chkg. Acct. #
Loan Acct. #
Name of Trade Reference
How Long
Contact Name
Telephone (or City & State)
Account #
I / WE AUTHORIZE THE RELEASE OF ANY CREDIT OR FINANCIAL INFORMATION TO NEC AMERICA , INC.:
Signature: X Printed Name:

AUTHORIZED SIGNER & TITLE

---