Customer Information
CompanyName		Credit Contact
Division or Subsidiary of		Telephone Number
Type of Business		Federal I.D. Number
Address		Logicalis Contact
		Tax Exempt
	Yes      No
Billing Address		Duns Number
		Do you have EFT Capability
	Yes      No
Type of Entity
Corporation      Partnership      Proprietor      LLC      Other
Banking Information
Bank Name		Telephone Number           Fax Number
Address		Acct #
		Contact
Trade References
Supplier Name		Telephone Number           Fax Number
Address		Acct #
		Contact
Supplier Name		Telephone Number           Fax Number
Address		Acct #
		Contact
Supplier Name		Telephone Number           Fax Number
Address		Acct #
		Contact
Revised 7/27/05
If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain a statement, please send a written request to us at Logicalis, Attn: Credit Manager, 1750 South Telegraph Road, Suite 300, Bloomfield Hills, MI 48302 within 60 days of when you learn of our decision. We will send you a written statement of our reasons within 30 days of receiving your request for a statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applications on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into binding contracts); because all or part of the applicant’s income derives from any public assistance program; or because the application has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Opportunity, Washington, D.C. 20550. By clicking on "Submit" below you hereby authorize Logicalis, Inc. to investigate your credit, including, without limitation, all banking and open trade references on this application. You also represent that all the information contained and submitted herewith is true and correct and authorize all references, bank or otherwise, to release any requested information. You acknowledge receipt of a copy of this application. You understand that Logicalis' normal credit terms are Net 30 days and that Logicalis may add 18% interest per annum for any item not paid in accordance with terms. The terms of sale governing Logicalis sales of products and professional services are available at www.us.logicalis.com/tcsales.pdf. You also agree that payment for all products received from Logicalis shall be your responsibility.