Credit Application

Credit Application and Agreement

Please complete this online application. Teledyne DALSA keeps submitted information in strict confidence in accordance with our Privacy Policy.

* Fields marked with an asterisk are required. Without this information, we cannot process your application.

You may also be asked to supply copies of relevant tax exemption certificates.


 * Company Information


 * Legal Corporate Name:
Subsidiary of:
Division of:
D&B #:
Web Address:
  * Street Address:
  * City:
 * State:
  * Country
 * Zip Code:
 * Phone:

  * Federal Tax #:
(US only)
You are required to attach all copies of your tax exemption certificates on this application.

  * Attachment
(optional; required for US; 10 MB max)

Market:

   If "Other", please specify:

Market Relationship:


Corporate Officers
 
  * President:
  * Senior Financial Officer:
Accounts Payable
  
  * Contact name:
  * Email:
Routing Information
  * Customer Location


  * Teledyne DALSA Division from which you will buy


Teledyne DALSA Sales Contact For faster processing, please indicate the name of your Teledyne DALSA sales contact.


Trade References:

  * Company Name:
Fax Number:
Contact Email:
  * Company Name:
Fax Number:
Contact Email:

Terms and Conditions
  Usual terms of sale are payment in full thirty (30) days from date of invoice, unless otherwise specified in writing, by the seller. Default of payment will result in a 1.5% monthly interest rate charge (18% per annum) on all past due amounts. The applicant does hereby authorize Teledyne DALSA to conduct all credit investigations necessary for approval of this application. Terms of credit must be approved and are not automatically granted. I understand and accept that Teledyne DALSA uses only electronic invoicing delivery methods.

Privacy Policy and Consent: I consent to the use of this information for the purpose described above.
  *
  * Applicant's Name
  * Applicant's Email
   


 

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