Reseller Application Form

If you are a company and would like to be qualified as a Reseller/Distributor and/or receive quantity pricing for your business needs, please fill out this online application. You can skip the EIN and State Resale Number if you are located outside of the United States. One of our account managers will contact you as soon as we received all the required information.

Company Information:

Company Name:	*
Contact Name:	*
Federal Tax ID (EIN):
State Resale Number:
Street Address:	*
City:	*
State:	*
Zip Code:	*
Country:	*
Tel #:	*
Fax #:
E-mail:	*
Company Website:
AP Contact:
AP Number:

Nature of your business (Select all that apply):

Credit Information (Optional)

*You can skip to the bottom if you are not applying for credit.

FOR: COD

Net 15

Net 30

Bank References:

Bank Name:
Telephone NO:
Contact Person:
Address:
City:
State:
Zip Code:

Credit References:

Company Name:
Contact Name:
Telephone#:
Address:
City:
State:
Zip Code:

Company Name:
Contact Name:
Telephone#:
Address:
City:
State:
Zip Code:

Company Name:
Contact Name:
Telephone#:
Address:
City:
State:
Zip Code:

This optional credit application and agreement are submitted by Customer to Xenarc Technologies Corporation (Xenarc) in order to obtain trade credit. Customer agrees to make payment in full to Xenarc Technologies Corporation for all amounts due according to a Xenarc invoice on or before the due date. The Customer also agrees to pay interest on all amounts that are past due. Interest will be charged as 1.5% per month or the highest rate allowed by law. Returned checks (NSF) will be charged a $25 penalty for each check. If Customer should default on any payment(s), Xenarc has reserved the right to declare all invoice amounts due and payable without notice to Customer. Additionally, Customer agrees to provide Xenarc with current credit information upon request and to provide an annual statement to Xenarc as a condition for the continued extension of credit. The undersigned certifies that all of the information contained herein and any attachment to be true and correct to the best of their information, knowledge, and belief. Customer agrees to adhere to credit service policies and procedures established by Xenarc and published in Xenarc’s literature.