creditapp.ecrinternational.com
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24.105.169.184
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URL:
https://creditapp.ecrinternational.com/
Submission: On November 08 via automatic, source certstream-suspicious — Scanned from IT
Submission: On November 08 via automatic, source certstream-suspicious — Scanned from IT
Form analysis 1 forms found in the DOM
Name: theForm — POST new_application_action.asp
<form action="new_application_action.asp" method="post" onsubmit="return checkForm(this);" id="theForm" name="theForm">
<table align="center" width="60%">
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<td align="center">2201 Dwyer Avenue - Utica, NY 13501 | Phone: 315-797-1310 - Fax: 315-797-1539 <br><br>
<font size="+1">
<b>CONFIDENTIAL CREDIT APPLICATION</b>
</font>
</td>
</tr>
</tbody>
</table>
<table align="center" width="60%" border="0">
<tbody>
<tr>
<td align="center" colspan="2"><b>
<span class="form-required" title="This field is required.">*</span> Required Fields <u>MUST</u> be Completed</b>
<br>
</td>
</tr>
<tr>
<td align="left" colspan="2">
<b>Requested Credit:</b> which may be increased or decreased at the sole discretion of ECR International, Inc.<br>
<b>$</b> <input type="text" name="app_requested_credit" size="20">
</td>
</tr>
<tr>
<td align="left" colspan="2">
<b>ECR Sales Rep:</b> <br>
<input type="text" name="app_ecr_sales_rep" size="80">
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
<tr>
<td colspan="3">
<font size="+1">Company Information</font>
</td>
</tr>
<tr>
<td colspan="3">
<hr>
</td>
</tr>
<tr>
<td align="left" colspan="2">
<b><u>Full Legal Name</u>:</b> of corporation, partnership or sole proprietorship (As on your business license or charter) <span class="form-required" title="This field is required.">*</span><br>
<input type="text" name="app_full_legal_name" size="80">
</td>
</tr>
<tr>
<td align="left" width="70%">
<b>DBA or T/A:</b> <br><input type="text" name="app_dba" size="60"><br>
<font size="1">(The name which you do business, if different from above)</font>
</td>
<td><b>Date Business began:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_date_business_began" size="15"></td>
</tr>
<tr>
<td align="left">
<b>Street:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_street_address" size="60"><br>
<font size="1">(If post office box, then also include street address)</font>
</td>
<td><b>Annual Sales:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_annual_sales" size="15"></td>
</tr>
<tr>
<td align="left">
<table>
<tbody>
<tr>
<td><b>City:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_city" size="20"></td>
<td><b>State:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_state" size="2"></td>
<td><b>Zip Code:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_zip_code" size="6"></td>
</tr>
</tbody>
</table>
</td>
<td><b>Phone:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_phone" size="15"></td>
</tr>
<tr>
<td align="left">
<b>Name of Company President / Owner:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_name_of_owner" size="60">
</td>
<td><b>Fax:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_fax" size="15"></td>
</tr>
<tr>
<td align="left">
<b><u>Business Legal Entity</u>:</b> <span class="form-required" title="This field is required.">*</span><br>
<input type="radio" name="app_business_entity" value="Corporation"> Corporation <input type="radio" value="Limited Liability Company" name="app_business_entity"> Limited Liability Company <input
type="radio" value="Partnership" name="app_business_entity"> Partnership <input type="radio" value="Sole Proprietorship" name="app_business_entity"> Sole Proprietorship
</td>
<td><b>County:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_county" size="15"></td>
</tr>
<tr>
<td align="left">
<b>State where organized:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_state_organized" size="15">
</td>
<td>
<font size="1">Note: if you are exempt from <b><u>Sales and Use Tax</u></b> please check the box below and after you complete the form you can upload a copy of the relevant resale or exempt state-approved certificate.</font>
</td>
</tr>
<tr>
<td align="left">
<b>Federal Tax ID Number:</b> <span class="form-required" title="This field is required.">*</span><br><input type="text" name="app_fed_tax_id_number" size="15">
</td>
<td>
<font size="1">Without certificate tax will be charged.<br>You will be able to upload your W-9 form once you complete the application.</font><br>Tax Exempt: <input type="checkbox" name="app_tax_exempt" value="Yes">
</td>
</tr>
<tr>
<td align="left" colspan="2">
<b>Parent Company Address:</b><br><input type="text" name="app_parent_company_address" size="80">
</td>
</tr>
<tr>
<td colspan="2"> </td>
</tr>
</tbody>
</table>
<table align="center" width="60%">
<tbody>
<tr>
<td colspan="6">
<font size="+1">Management Information</font>
</td>
</tr>
<tr>
<td colspan="6">
<hr>
</td>
</tr>
<tr>
<td align="center" colspan="6"><b>
<u>List below the name of Officers, Partners, Managing Members, and/or Sole Proprietor</u>: <span class="form-required" title="This field is required.">*</span></b>
<br>
</td>
</tr>
<tr>
<td align="left"><b>Name:</b></td>
<td align="left"><b>Home Address:</b></td>
<td align="left"><b>Home Phone:</b></td>
<td align="left"><b>Title:</b></td>
<td align="left"><b>Email:</b></td>
</tr>
<tr>
<td><input type="text" size="20" name="app_officer_name_1"></td>
<td><input type="text" size="20" name="app_officer_address_1"></td>
<td><input type="text" size="10" name="app_officer_phone_1"></td>
<td><input type="text" size="15" name="app_officer_title_1"></td>
<td><input type="text" size="20" name="app_officer_email_1"></td>
</tr>
<tr>
<td><input type="text" size="20" name="app_officer_name_2"></td>
<td><input type="text" size="20" name="app_officer_address_2"></td>
<td><input type="text" size="10" name="app_officer_phone_2"></td>
<td><input type="text" size="15" name="app_officer_title_2"></td>
<td><input type="text" size="20" name="app_officer_email_2"></td>
</tr>
<tr>
<td><input type="text" size="20" name="app_officer_name_3"></td>
<td><input type="text" size="20" name="app_officer_address_3"></td>
<td><input type="text" size="10" name="app_officer_phone_3"></td>
<td><input type="text" size="15" name="app_officer_title_3"></td>
<td><input type="text" size="20" name="app_officer_email_3"></td>
</tr>
<tr>
<td colspan="6"> </td>
</tr>
</tbody>
</table>
<table align="center" width="60%">
<tbody>
<tr>
<td colspan="6">
<font size="+1">Company Information</font>
</td>
</tr>
<tr>
<td colspan="6">
<hr>
</td>
</tr>
<tr>
<td align="left"><b>Category:</b></td>
<td align="left"><b>First Name:</b></td>
<td align="left"><b>Last Name:</b></td>
<td align="left"><b>Title:</b></td>
<td align="left"><b>Email:</b></td>
</tr>
<tr>
<td>Accounts Payable</td>
<td><input type="text" size="15" name="app_accounts_payable_first_name"></td>
<td><input type="text" size="20" name="app_accounts_payable_last_name"></td>
<td><input type="text" size="10" name="app_accounts_payable_title"></td>
<td><input type="text" size="20" name="app_accounts_payable_email"></td>
</tr>
<tr>
<td>Operations/General Manager</td>
<td><input type="text" size="15" name="app_general_manager_first_name"></td>
<td><input type="text" size="20" name="app_general_manager_last_name"></td>
<td><input type="text" size="10" name="app_general_manager_title"></td>
<td><input type="text" size="20" name="app_general_manager_email"></td>
</tr>
<tr>
<td>Sales Manager</td>
<td><input type="text" size="15" name="app_sales_manager_first_name"></td>
<td><input type="text" size="20" name="app_sales_manager_last_name"></td>
<td><input type="text" size="10" name="app_sales_manager_title"></td>
<td><input type="text" size="20" name="app_sales_manager_email"></td>
</tr>
<tr>
<td>Purchasing Manger</td>
<td><input type="text" size="15" name="app_purchasing_manager_first_name"></td>
<td><input type="text" size="20" name="app_purchasing_manager_last_name"></td>
<td><input type="text" size="10" name="app_purchasing_manager_title"></td>
<td><input type="text" size="20" name="app_purchasing_manager_email"></td>
</tr>
<tr>
<td>Other</td>
<td><input type="text" size="15" name="app_other_manager_first_name"></td>
<td><input type="text" size="20" name="app_other_manager_last_name"></td>
<td><input type="text" size="10" name="app_other_manager_title"></td>
<td><input type="text" size="20" name="app_other_manager_email"></td>
</tr>
<tr>
<td colspan="6"> </td>
</tr>
</tbody>
</table>
<table align="center" width="60%">
<tbody>
<tr>
<td colspan="6">
<font size="+1">General Information</font>
</td>
</tr>
<tr>
<td colspan="6">
<hr>
</td>
</tr>
<tr>
<td align="center" colspan="6"><b>
<u>Please check the following online services that you would like to sign up for</u>:</b>
<br>
</td>
</tr>
<tr>
<td align="left" width="50%"><input type="checkbox" name="app_services" value="Monthly AR Statement Retrieval"> Monthly AR Statement Retrieval</td>
<td>Email: <input type="text" size="20" name="app_monthly_ar_statement_email"></td>
</tr>
<tr>
<td align="left"><input type="checkbox" name="app_services" value="Invovices"> Invoices</td>
<td>Email: <input type="text" size="20" name="app_invovices_email"></td>
</tr>
<tr>
<td align="left"><input type="checkbox" name="app_services" value="Web portal"> Web portal-catalog, pricing, literature, RMA request</td>
<td>Email: <input type="text" size="20" name="app_portal_email"></td>
</tr>
<tr>
<td colspan="6"> </td>
</tr>
</tbody>
</table>
<table align="center" width="60%" border="0">
<tbody>
<tr>
<td colspan="10">
<font size="+1">Trade References</font>
</td>
</tr>
<tr>
<td colspan="10">
<hr>
</td>
</tr>
<tr>
<td align="center" colspan="10"><b>
<u>Please complete all information</u>:</b><br>(Or you can upload reference sheets once you complete this application.)<br>
<br>
</td>
</tr>
<tr>
<td align="left" nowrap=""><b>1.</b> Name:<br><input type="text" size="30" name="app_trade_name_1"></td>
<td align="left">City:<br><input type="text" size="20" name="app_trade_city_1"></td>
<td align="left">State:<br><input type="text" size="2" name="app_trade_state_1"></td>
<td align="left">Zip:<br><input type="text" size="5" name="app_trade_zip_1"></td>
<td align="left">Account Number:<br><input type="text" size="10" name="app_trade_account_number_1"></td>
</tr>
<tr>
<td align="left">Phone:<br><input type="text" size="20" name="app_trade_phone_1"></td>
<td align="left">Fax:<br><input type="text" size="20" name="app_trade_fax_1"></td>
<td colspan="3">Email:<br><input type="text" size="35" name="app_trade_email_1"></td>
</tr>
<tr>
<td colspan="10"> </td>
</tr>
<tr>
<td align="left" nowrap=""><b>2.</b> Name:<br><input type="text" size="30" name="app_trade_name_2"></td>
<td align="left">City:<br><input type="text" size="20" name="app_trade_city_2"></td>
<td align="left">State:<br><input type="text" size="2" name="app_trade_state_2"></td>
<td align="left">Zip:<br><input type="text" size="5" name="app_trade_zip_2"></td>
<td align="left">Account Number:<br><input type="text" size="10" name="app_trade_account_number_2"></td>
</tr>
<tr>
<td align="left">Phone:<br><input type="text" size="20" name="app_trade_phone_2"></td>
<td align="left">Fax:<br><input type="text" size="20" name="app_trade_fax_2"></td>
<td colspan="3">Email:<br><input type="text" size="35" name="app_trade_email_2"></td>
</tr>
<tr>
<td colspan="10"> </td>
</tr>
<tr>
<td align="left" nowrap=""><b>3.</b> Name:<br><input type="text" size="30" name="app_trade_name_3"></td>
<td align="left">City:<br><input type="text" size="20" name="app_trade_city_3"></td>
<td align="left">State:<br><input type="text" size="2" name="app_trade_state_3"></td>
<td align="left">Zip:<br><input type="text" size="5" name="app_trade_zip_3"></td>
<td align="left">Account Number:<br><input type="text" size="10" name="app_trade_account_number_3"></td>
</tr>
<tr>
<td align="left">Phone:<br><input type="text" size="20" name="app_trade_phone_3"></td>
<td align="left">Fax:<br><input type="text" size="20" name="app_trade_fax_3"></td>
<td colspan="3">Email:<br><input type="text" size="35" name="app_trade_email_3"></td>
</tr>
<tr>
<td colspan="10"> </td>
</tr>
<tr>
<td align="left" nowrap=""><b>4.</b> Name:<br><input type="text" size="30" name="app_trade_name_4"></td>
<td align="left">City:<br><input type="text" size="20" name="app_trade_city_4"></td>
<td align="left">State:<br><input type="text" size="2" name="app_trade_state_4"></td>
<td align="left">Zip:<br><input type="text" size="5" name="app_trade_zip_4"></td>
<td align="left">Account Number:<br><input type="text" size="10" name="app_trade_account_number_4"></td>
</tr>
<tr>
<td align="left">Phone:<br><input type="text" size="20" name="app_trade_phone_4"></td>
<td align="left">Fax:<br><input type="text" size="20" name="app_trade_fax_4"></td>
<td colspan="3">Email:<br><input type="text" size="35" name="app_trade_email_4"></td>
</tr>
<tr>
<td colspan="10"> </td>
</tr>
</tbody>
</table>
<table align="center" width="60%" border="0">
<tbody>
<tr>
<td colspan="10">
<font size="+1">Bank References</font>
</td>
</tr>
<tr>
<td colspan="10">
<hr>
</td>
</tr>
<tr>
<td align="center" colspan="10"><b>
<u>Please complete all information</u>: </b>
<br>
</td>
</tr>
<tr>
<td align="left">Bank:<br><input type="text" size="30" name="app_bank_name"></td>
<td align="left">Contact:<br><input type="text" size="30" name="app_bank_contact_name"></td>
<td align="left">Email:<br><input type="text" size="30" name="app_bank_email"></td>
</tr>
<tr>
<td align="left">Address:<br><input type="text" size="30" name="app_bank_address"></td>
<td align="left">City:<br><input type="text" size="20" name="app_bank_city"></td>
<td align="left">State:<br><input type="text" size="10" name="app_bank_state"></td>
</tr>
<tr>
<td align="left">Account Number:<br><input type="text" size="20" name="app_bank_account_number"></td>
<td align="left">Phone:<br><input type="text" size="20" name="app_bank_phone"></td>
<td align="left">Fax:<br><input type="text" size="20" name="app_bank_fax"></td>
</tr>
<tr>
<td colspan="10"> </td>
</tr>
</tbody>
</table>
<hr> Applicant agrees to pay according to the terms and conditions stated herein. Creditor reserves the right to assess a monthly service charge on account paid outside credit terms to the maximum amount permitted per jurisdiction. All goods are
sold F.O.B. shipping point with the risk of loss or damage shifting to the Applicant upon Creditor’s delivery to the Applicant or common carrier. Creditor reserves the right to cease extension of credit without notice. Applicant expressly agrees
that it shall be liable and pay all attorneys’ fees, collection costs and count fees, and any other expenses, whether or not incurred in connection with litigation, including but not limited to attorneys’ fees and costs associated with the
enforcement of any of the terms of this Application and attorneys’ fees and costs resulting from a default under this Application. <br><br> The above information is being provided in conjunction with a request of open credit terms from ECR
International, Inc. and its subsidiaries, divisions and affiliates (collectively “ECR”). I hereby certify under penalty of perjury that the information provided is true to the best of my knowledge. If this Application is accepted by ECR, the
undersigned agrees to the terms and conditions state herein and changed from time to time. The undersigned further agrees that all issues and disputes relating to any credit arrangement extended hereunder shall be governed in accordance with a
competent jurisdiction chosen at the discretion of ECR, without refence to conflicts of laws principles. Applicant also agrees if there are any important changes to your business entity including change of ownership, change of name, change of
address you will notify us immediately. <br><br>
<table align="center" width="60%">
<tbody>
<tr>
<td>Owner/Officer: <span class="form-required" title="This field is required.">*</span> </td>
<td><input type="text" name="app_person_completing_form" size="30"></td>
</tr>
<tr>
<td>Title: <span class="form-required" title="This field is required.">*</span> </td>
<td><input type="text" name="app_person_comleting_form_title" size="30"></td>
</tr>
<tr>
<td>Date: <span class="form-required" title="This field is required.">*</span> </td>
<td><input type="hidden" value="11/8/2024" name="app_person_comleting_form_date">11/8/2024</td>
</tr>
</tbody>
</table>
<fieldset class="webform-component-fieldset webform-component--terms-of-acceptance-and-signature form-wrapper">
<legend><span class="fieldset-legend">TERMS OF ACCEPTANCE and SIGNATURE</span></legend>
<div class="fieldset-wrapper">
<div class="fieldset-description">
</div>
<div class="form-item webform-component webform-component-textfield webform-component--terms-of-acceptance-and-signature--electronic-signature">
<label for="edit-submitted-terms-of-acceptance-and-signature-electronic-signature">Electronic Signature <span class="form-required" title="This field is required.">*</span></label>
<input required="required" type="text" id="edit-submitted-terms-of-acceptance-and-signature-electronic-signature" name="submitted[terms_of_acceptance_and_signature][electronic_signature]" value="" size="60" maxlength="128"
class="form-text required">
<div class="description">Please type your First and Last Name </div>
</div>
<div class="form-item webform-component webform-component-checkboxes webform-component--terms-of-acceptance-and-signature--acceptance-checkbox">
<label class="element-invisible" for="edit-submitted-terms-of-acceptance-and-signature-acceptance-checkbox">Acceptance Checkbox <span class="form-required" title="This field is required.">*</span></label>
<div id="edit-submitted-terms-of-acceptance-and-signature-acceptance-checkbox" class="form-checkboxes">
<div class="form-item form-type-checkbox form-item-submitted-terms-of-acceptance-and-signature-acceptance-checkbox-0">
<input required="required" type="checkbox" id="edit-submitted-terms-of-acceptance-and-signature-acceptance-checkbox-1" name="submitted[terms_of_acceptance_and_signature][acceptance_checkbox][0]" value="0" class="form-checkbox"> <label
class="option" for="edit-submitted-terms-of-acceptance-and-signature-acceptance-checkbox-1"> I understand that checking this box constitutes a legal signature confirming that I, the [applicant, requestor, etc.] for this
Application, warrant the truthfulness of the information provided in this application.</label>
<br><br>
<div class="g-recaptcha" data-sitekey="6Ldndm8UAAAAAC7EH5Y4XsmI_NJtDpG4rrMBntaw">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-fxxvbpu75raw" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox allow-storage-access-by-user-activation"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6Ldndm8UAAAAAC7EH5Y4XsmI_NJtDpG4rrMBntaw&co=aHR0cHM6Ly9jcmVkaXRhcHAuZWNyaW50ZXJuYXRpb25hbC5jb206NDQz&hl=it&v=-ZG7BC9TxCVEbzIO2m429usb&size=normal&cb=5am2dwfgbgtn"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<div class="form-actions form-wrapper" id="edit-actions">
<center><input type="submit" id="edit-submit--2" name="op" value="Submit Application" class="form-submit"><br><br>Once you submit this application you will have the opportunity to upload documents.</center>
</div>
</div>
</div>
</div>
</div>
</fieldset>
</form>Text Content
ECR Confidential Credit Application 2201 Dwyer Avenue - Utica, NY 13501 | Phone: 315-797-1310 - Fax: 315-797-1539 CONFIDENTIAL CREDIT APPLICATION * Required Fields MUST be Completed Requested Credit: which may be increased or decreased at the sole discretion of ECR International, Inc. $ ECR Sales Rep: Company Information -------------------------------------------------------------------------------- Full Legal Name: of corporation, partnership or sole proprietorship (As on your business license or charter) * DBA or T/A: (The name which you do business, if different from above) Date Business began: * Street: * (If post office box, then also include street address) Annual Sales: * City: * State: * Zip Code: * Phone: * Name of Company President / Owner: * Fax: * Business Legal Entity: * Corporation Limited Liability Company Partnership Sole Proprietorship County: * State where organized: * Note: if you are exempt from Sales and Use Tax please check the box below and after you complete the form you can upload a copy of the relevant resale or exempt state-approved certificate. Federal Tax ID Number: * Without certificate tax will be charged. You will be able to upload your W-9 form once you complete the application. Tax Exempt: Parent Company Address: Management Information -------------------------------------------------------------------------------- List below the name of Officers, Partners, Managing Members, and/or Sole Proprietor: * Name:Home Address:Home Phone:Title:Email: Company Information -------------------------------------------------------------------------------- Category:First Name:Last Name:Title:Email: Accounts Payable Operations/General Manager Sales Manager Purchasing Manger Other General Information -------------------------------------------------------------------------------- Please check the following online services that you would like to sign up for: Monthly AR Statement RetrievalEmail: InvoicesEmail: Web portal-catalog, pricing, literature, RMA requestEmail: Trade References -------------------------------------------------------------------------------- Please complete all information: (Or you can upload reference sheets once you complete this application.) 1. Name: City: State: Zip: Account Number: Phone: Fax: Email: 2. Name: City: State: Zip: Account Number: Phone: Fax: Email: 3. Name: City: State: Zip: Account Number: Phone: Fax: Email: 4. Name: City: State: Zip: Account Number: Phone: Fax: Email: Bank References -------------------------------------------------------------------------------- Please complete all information: Bank: Contact: Email: Address: City: State: Account Number: Phone: Fax: -------------------------------------------------------------------------------- Applicant agrees to pay according to the terms and conditions stated herein. Creditor reserves the right to assess a monthly service charge on account paid outside credit terms to the maximum amount permitted per jurisdiction. All goods are sold F.O.B. shipping point with the risk of loss or damage shifting to the Applicant upon Creditor’s delivery to the Applicant or common carrier. Creditor reserves the right to cease extension of credit without notice. Applicant expressly agrees that it shall be liable and pay all attorneys’ fees, collection costs and count fees, and any other expenses, whether or not incurred in connection with litigation, including but not limited to attorneys’ fees and costs associated with the enforcement of any of the terms of this Application and attorneys’ fees and costs resulting from a default under this Application. The above information is being provided in conjunction with a request of open credit terms from ECR International, Inc. and its subsidiaries, divisions and affiliates (collectively “ECR”). I hereby certify under penalty of perjury that the information provided is true to the best of my knowledge. If this Application is accepted by ECR, the undersigned agrees to the terms and conditions state herein and changed from time to time. The undersigned further agrees that all issues and disputes relating to any credit arrangement extended hereunder shall be governed in accordance with a competent jurisdiction chosen at the discretion of ECR, without refence to conflicts of laws principles. Applicant also agrees if there are any important changes to your business entity including change of ownership, change of name, change of address you will notify us immediately. Owner/Officer: * Title: * Date: * 11/8/2024 TERMS OF ACCEPTANCE and SIGNATURE Electronic Signature * Please type your First and Last Name Acceptance Checkbox * I understand that checking this box constitutes a legal signature confirming that I, the [applicant, requestor, etc.] for this Application, warrant the truthfulness of the information provided in this application. Once you submit this application you will have the opportunity to upload documents.