MyTana Summer

!

Summer 2020

Please mail form to: MyTana LLC, 746 Selby Ave St. Paul, MN 55104 Or fax to: 651.222.1739

Order Form | Net30 Credit Application

Company Information Company Name

Phone

Business Address

Fax

City, State

Zip

Email

Order Form Shipping Address (if different from above)

Part Number or Description

Quantity

Unit Price

TOTAL

Purchase Total $ * Shipping $ ** MN Sales Tax $ Grand Total $

Payment Information

Credit Card# _______________________________________ Exp Date ___________ CVV ____________ Name on card _________________________________________________________________ Signature _____________________________________________________________________

* Please call for shipping charges ** MN residents add 6.5% sales tax (7% in metro areas)

Credit Application

For Net30 payment terms with MyTana only. For financing/leasing options, visit MyTana.com.

SS# ( * Required) ___________ - _________ - ________

Name of Owner

Address (if different)

Years in business?

City, State

Zip _________________________

Name of Bank _________________________________________ Acct # ___________________________________ Address ______________________________________________ Phone ___________________________________ City, State/Zip_________________________________________ Contact ___________________________________ 1. Reference Company ____________________________________ Phone ___________________________________ Address _____________________________________________ Contact ___________________________________ City, State, Zip_________________________________________ ___________________________________ 2. Reference Company ____________________________________ Phone ___________________________________ Address _____________________________________________ Contact ___________________________________ City, State, Zip_________________________________________ ___________________________________ 3. Reference Company ____________________________________ Phone ___________________________________ Address _____________________________________________ Contact ___________________________________ City, State, Zip_________________________________________ ___________________________________ Authorization I hereby certify that the information contained herein is true and accurate to the best of my knowledge. I hereby authorize the release of credit information from references listed above, and understand MyTana will run a report on my credit history. * Applicant’s signature is required. Bank Reference Trade References

*Applicant Signature ____________________________________________________ Date ___________________________