230 Paseo Sonrisa - Walnut, CA 91789
Tel: (909) 594-6282 Fax: (909) 598-3465

Dynapower USA Account Application

LEGAL BUSINESS NAME
DATE ESTABLISHED
PHONE


 FAX:
DBA
FEDERAL ID NO.
BILLING ADDRESS


 CITY


 STATE
ZIP
OWNER/PRESIDENT


  
TREASURER
[ ]CORPORATION


 [ ]LIMITED PARTNERSHIP
[ ]GENERAL PARTNERSHIP
TYPE OF BUSINESS


   # OF EMPLOYEES


  
ACCT. PAYABLE CONTACT / E-MAIL:
DO YOU USE PURCHASE ORDERS?


  
NAME OF PURCHASING AGENT / E-MAIL:
IS MERCHANDISE FOR RESALE?


  
NAME OF OUR SALES REPRESENTATIVE



Credit Card Information

CIRCLE ONE:    VISA    MASTERCARD    AMEX    DISCOVER
CARD NUMBER:


  
EXPIRATION DATE:
CARDHOLDER NAME:
BILLING ADDRESS
CITY
ST
ZIP


  
PHONE:

By signing, I understand that the standard payment term is by company credit card. I also understand and
agree that the information provided is for the purpose of opening an account with Dynapower U.S.A.
I hereby authorize any charges for products purchased or services rendered from Dynapower U.S.A. and understand that
it will be my responsibility and obligation to inform Dynapower U.S.A. of any changes that are made in the
above account information.

By:___________________________   Title:_________________________    Date:____________________________