DGI Credit Application

Please fill in all required fields, marked with an asterisk (*).
If you would like to fill out the paper version of this application, you may fax it to 1-847-495-3488.
This application will take X days to process, maximum. Until you are approved, any orders against your Open Account will be held in processing.

REQUIRED fields are marked with an asterisk (*).

Company Information

Exact Name of Firm * :
FEIN * :
DUNS :
Type of Business * :
Years in Business * :
Type of Business Entity:	Other:

Billing Address

Select country :	USA Canada Other
Street Address 1 * :
Street Address 2:
City * :
State:
Postal Code * :	-
Country: *

Company Fax * :	XXX-XXX-XXXX
Principle Contact Email Address * :

Sales Contact

Full Name * :
Email Address * :

Accounts Payable Contact

Full Name * :
Email Address * :

Owner of Company

Full Name* :
Select country :	USA Canada Other
Address 1 * :
Address 2:
City * :
State:
Postal Code * :	-
Country: *

SSN * :	XXX-XX-XXXX
Office Phone * :	XXX-XXX-XXXX
Home Phone * :	XXX-XXX-XXXX

Person Authorized to Purchase Goods on Behalf of Company #1

Full Name * :
SSN * :	XXX-XX-XXXX

Person Authorized to Purchase Goods on Behalf of Company #2

Full Name * :
SSN * :	XXX-XX-XXXX

Credit and Trade Reference #1

Full Name* :
Select country :	USA Canada Other
Address 1 * :
Address 2:
City * :
State:
Postal Code * :	-
Country: *

Phone * :	XXX-XXX-XXXX
Relationship * :

Credit and Trade Reference #2

Full Name* :
Select country :	USA Canada Other
Address 1 * :
Address 2:
City * :
State:
Postal Code * :	-
Country: *

Phone * :	XXX-XXX-XXXX
Relationship * :

Bank Reference

Bank Name* :
Select country :	USA Canada Other
Address 1 * :
Address 2:
City * :
State:
Postal Code * :	-
Country: *

Contact * :
Accounts Maintained * :	Checking Savings

Agreement

DGI MAKES NO WARRANTY, EXPRESS OR IMPLIED, THAT PRODUCTS ARE MERCHANTABLE OR FIT FOR A PARTICULAR PURPOSE, OR THAT PRODUCTS WILL CONFORM TO ILLUSTRATIONS OR DESCRIPTIONS. ANY LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES IS EXPRESSLY DISCLAIMED. DGI's liability is limited to, and in any event will not exceed, the purchase price paid. All returns must be authorized in advance and may be subject to a restocking charge. DGI does not guarantee compliance with any state or local codes and regulations governing suitability of products, and is not responsible for how the products are installed or used. DGI makes no warranty with respect to the contents of any product literature, and DGI reserves the right to change prices or modify any catalog or brochure at any time. State and local tax will be charged unless a sales tax exemption certification has been provided to DGI. Payment, in U.S. Dollars, is due upon delivery. Credit terms, if approved, are 30 days from date of invoice. Purchaser agrees to return, upon demand by DGI, any merchandise for which payment has not been timely tendered. Purchaser agrees to reimburse DGI for the cost, including attorneys fees or other charges, incurred to collect any amounts past due. Purchaser agrees to pay DGI interest at the rate of the lesser of (i) 1.5% per month or (ii) the highest interest rate permitted by applicable law for any outstanding indebtedness to DGI (including expenses of collection) which is not timely paid. Purchaser agrees to operate the products purchased in a safe manner, not remove or alter any safety features of the product and indemnify and hold DGI harmless from any claim or liability resulting from actions with respect to the product. Failure to immediately return the merchandise described herein constitutes conclusive acceptance of the merchandise and of these Terms and Conditions. The information given above is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize DGI Company, its affiliates, nominees, agents, and attorneys in fact or law to investigate and verify all of the above information including all trade, credit, and banking references. I Understand the Terms of the Agreement
Your Name * :
Your Title * :