Allied High Tech: Online Ordering Application

Submit a request for credit with Allied...

Credit Request Form

Please complete the form provided below, review your entries for accuracy, then click the "Generate Credit Request" button at the bottom of this page. This will create an Allied credit application for you to print, sign and fax to Allied @ (310) 762-6808 (worldwide). We will respond promptly to your request!

(* = required field)

*Company:
{company_ERROR}

*Address:
{address1_ERROR}
{address1_ERROR}

*City: {city_ERROR} State:

Zip Code: *Country: {country_ERROR}

*Phone Number:
{phone_ERROR} Extension:

*Fax:
{fax_ERROR}

*E-mail Address:
{email_addr_ERROR}

{corp_part_ERROR}*Corporation or Partnership?
Corporation
Partnership

*Federal Tax ID Number:
{tax_id_ERROR}

*Contact Name	Mr. Mrs. Ms.
First Name:	{name_first_ERROR}
Last Name:	{name_last_ERROR}
*Contact Position or Title: {p_title_ERROR}

Billing Contact Name	Mr. Mrs. Ms.
First Name:	{Bill_name_first_ERROR}
Last Name:	{Bill_name_last_ERROR}

Complete Billing Address: (if different than address above)

Please check the boxes that apply:
Educational Institution
Tax Exempt (attach resale card to this application)
Note: Only customers in California are charged sales tax.

Bank Information:

*Bank Name:
{bank_name_ERROR}

*Address:
{bank_address1_ERROR}
{bank_address1_ERROR}

*City: {bank_city_ERROR} State:

Zip Code: *Country: {bank_country_ERROR}

*Phone Number:
{bank_phone_ERROR}

Business References: (3 required)

*Company #1:
{bus1_company_ERROR}

*Address:
{bus1_address1_ERROR}
{bus1_address1_ERROR}

*City: {bus1_city_ERROR} State:

Zip Code: *Country: {bus1_country_ERROR}

*Phone Number:
{bus1_phone_ERROR}

*Company #2:
{bus2_company_ERROR}

*Address:
{bus2_address1_ERROR}
{bus2_address1_ERROR}

*City: {bus2_city_ERROR} State:

Zip Code: *Country: {bus2_country_ERROR}

*Phone Number:
{bus2_phone_ERROR}

*Company #3:
{bus3_company_ERROR}

*Address:
{bus3_address1_ERROR}
{bus3_address1_ERROR}

*City: {bus3_city_ERROR} State:

Zip Code: *Country: {bus3_country_ERROR}

*Phone Number:
{bus3_phone_ERROR}

Thank you for choosing Allied!