Credit Application

Credit Application and Agreement

  • Please complete this online application. 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:
Fax:
*Federal Tax #:
(US only)
You may be asked to provide copies of any exemption certificates.
Market:

   If "Other", please specify:

Market Relationship:


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

  * DALSA Division from which you will buy

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


Trade References:

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

Attachment (optional)
Attachment (10 Mb max)

Terms and Conditions
  Terms of sales 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 DALSA Inc. to conduct all credit investigations necessary for approval of this application. I understand and accept that DALSA Inc. 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