Iomega Solutions: Credit Request Form

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Iomega Credit Request

Application for credit terms is intended for purchases of $25,000 or more per year and orders greater than $500 submitted online through the Iomega Online Store.

Government and public education customers may fax their Purchase Orders greater than $500 directly to 801-332-4890 for processing and account setup. For single Purchase Orders less than $500 please click here to find an Iomega dealer near you.

If you are claiming tax-exempt status, please provide us with your Tax Exemption Certificate when you fax your credit application.

When you have filled out the form, click on the submit button, this will print a copy to your local printer. Please submit your initial Purchase Order of $500 or more with this form. Please sign and fax it to 801-332-4890 in order to complete the application process. Feel free to contact us at 1-800-723-2750 or direct@iomega.com if you have any questions. Thank you.

Company information
* = Required Information

* Company Name
* Contact Name
* Position
* E-mail Address
* Work Phone
Ext.
* Fax
* Bill to Address
* City
* State/Province
* Zip/Postal Code
* Country
Ship to Address (fill out, only if different from above)
City
State/Province
Zip/Postal Code
Country
* Federal ID #
* Year Business Established
Est. Annual Revenue (for re-sellers only)

* Doing Business As (DBA)

* Parent Company

*	Partnership Proprietorship Corporation Other
	If Partnership or Proprietorship is selected, please provide social security numbers of principals/partners

Social Security Numbers

*	Will Parent assume responsibility for debt, if necessary?	Yes No
	If yes, Parent Company officer's signature is required.

Bank Reference
* Name of Bank
* Contact
* Account Number
* FAX
Business Reference
* Name of Company
* Contact
* Telephone
* FAX

* Name of Company
* Contact
* Telephone
* FAX

Name of Company
Contact
Telephone
FAX


Is this purchase tax exempt?	Yes No
If yes, please FAX your exemption certificate with this form.