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	Contact Information
	Hours: 8am - 6pm Eastern Time, Monday - Friday Address: Horizon Datacom Solutions, Inc. 400 Lazelle Road, Suite 7 Columbus, Ohio 43240 Telephone: Local: 614.847.0400 Toll Free: 800.227.2362 Fax: 614.847.1112 More Contact Info

Credit Application

Please fill out the form below completely and accurately. Once we have reviewed your application, we will contact you via email regarding your new account status for credit approval. Fields in bold are required

Company Information

Company Name
D/B/A
	Corporation Partnership Sole Proprietor
D&B Number
D&B Rating
Telephone
Fax

Your Information

First Name
Last Name
Position
Department
Telephone	Ext
Fax
E-mail Address

Billing & Shipping Information

Bill-To

Billing Address
Billing Address 2
City
State/Province
Zip Code

Ship-To

	Check box if same as billing
Shipping Address
Shipping Address 2
City
State/Province
Zip Code

Ohio Tax Exempt Status

* In order to process your application we must receive a tax exempt certificate by fax or mail if your company's address is in Ohio

Bank Information

Name of Bank
Bank Address
Bank Address 2
City
State/Province
Zip Code
Bank Account Number
Bank Representative
Telephone	Ext
Fax

Trade References

Company
Address
Address 2
Telephone	Ext
Fax
Contact
E-mail Address

Company
Address
Address 2
Telephone	Ext
Fax
Contact
E-mail Address

Company
Address
Address 2
Telephone	Ext
Fax
Contact
E-mail Address

Release Information

By checking this box, I hereby authorize Horizon Datacom Solutions, Inc. to investigate, verify, and collect information, including but not limited to bank references, trade credit references, consumer and/or commercial credit reports. All information contained herein is to the best of my knowledge true and complete. We agree that all decisions with respect to the extension or continuation of credit shall be in the sole discretion of the creditor. If credit is to be granted we agree to pay all costs of collection and litigation on this account, if delinquent, In accordance with the laws of the creditor's state of incorporation.

Your Name
Your Title
Todays Date

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