Credit Application
Emerging Markets Broadband Media
One Technology Center
Attn: Bobby Dill, Mail Drop TC-13E
Tulsa, OK 74103
Tel. (918) 547-6540 Fax (918) 547-1109
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(* items are required)
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Full Legal Company Name:
*
Telephone:
*
Address:
*
City:
*
State:
*
Zip Code:
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Contact Person:
*
Title:
*
Email Address:
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Business Type:
Proprietorship
Partnership
Corporation
*
No. of Years in Business:
Name Used for Buying Purposes (Trade Name):
*
Full Name of Parent Company:
WCG SALES REPRESENTATIVE:
ESTIMATED MONTHLY CHARGES: $
TYPE OF SERVICE NEEDED (PLEASE CHECK):
FIBER
SATELLITE
TELEPORT
ADS
Bank References
: Transaction and Borrowing Institutions
*
Present Bank:
Name of Borrowing Bank:
Branch:
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Telephone:
*
Fax:
Branch:
Telephone:
Fax:
Name of Bank Officer:
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Account #:
Name of Bank Officer:
Account #:
AUDITED FINANCIAL STATEMENTS FOR THE LAST TWO FISCAL YEARS AND THE LATEST INTERIM STATEMENTS ARE REQUIRED.
FINANCIAL STATEMENTS: Enclosed
To Be Mailed On (date)
DUNS #:
Trade References:
Please provide four (4) references that reflect amounts comparable to your request.
Company Name
Address
Telephone #
Monthly Dollar Value
Contact Name
City, State Zip Code
Fax #
Last Transaction Date
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Applying Company Name:
Printed
Name of Person Signing:
*
Signature:
X
*
Date:
*
Title:
Everything stated in this application is true and correct to the best of my knowledge. It is understood Level 3 Communications, LLC (
Vyvx Services
) will retain this application whether or not it is approved.
Vyvx Services
and its designees are authorized to check our credit as necessary through our trade and bank references, credit reporting agencies and sources
Vyvx Services
reasonably deems necessary to obtain answers about credit experience. The undersigned understands that any extension of credit will include the obligation to pay finance charges on all past due balances of eighteen percent (18%) per annum. The undersigned further declares that the undersigned is duly authorized to sign this application on behalf of the person and/or company herein represented. Any information obtained pursuant to this application will be used in making a credit decision only and will be held in confidence by
Vyvx Services
and its designees.
You can also download
credit application
and fax the completed form to 918-547-1109.
Or directly e-mail your application to
Bobby.Dill@level3.com.