MicroScreen®
1106 South High Street,
South Bend, IN 46601
Phone:  574-232-4358
Fax:  574-234-7496
email:  info@microscreen.org
www.microscreen.org 		Credit Application

Stencil  Screen  

Billing Information:
Billing Company Name:
Billing Address:
Billing City:
Billing State:
 Zip:

 Shipping Information:
 Shipping Company Name:
 
 Shipping Address:
 
 
 Shipping City:
 
 Shipping State:
 		 Zip:

Purchasing Contact:
Name:
Phone:
E-Mail:

 User Contact:
 Name:
 
 Phone:
 
 E-Mail:
 

I will submit my Tax Exemption Certificate:
(must be submitted before account can be activated)

Credit References:  (3 trade, 1 bank)
Name:



 Address:
Telephone:



 Contact:

Requested By: