MDI Corp. is happy to accept Visa and MasterCard for payment of on-line orders.   
If you would prefer to place your order off-line, or you wish to open an account, 
please complete the following credit request and fax it to us at 229-228-5688.  
We'll process your request, and get right back to you!

MDI CORP - Confidential Customer Credit Application

Today's Date:  
Company Name:  
Billing Address:  
Shipping Address:  
Phone Number:  
Fax Number:  
Year Established:  
Subsidiary of:  
Type of Business:

[ ] Corp.       [ ] Partnership      [ ] Proprietorship    

Number of Employees:  
Federal Tax ID Number:  
DUNS Number:  

Principle Officers / Owners

Name Title Home Address
Type of Business:  
Anticipated Monthly Requirements: $
Estimated Company Net Worth: $

Trade References 
(Name, Address, Etc., of your suppliers of major products & services.  Your faxed trade sheet with reference is allowed for this block.)

Firm Name Address Phone Fax

Bank References 

Bank Name Contact Phone Fax

I, the undersigned, warrant that the foregoing is true as of this date, and is furnished to MDI Corp. for the purpose of obtaining a line of credit.  Outstanding balances are subject to a 1% per month interest.  If in default of payment of goods when due, the undersigned agrees to pay 18% per annum interest on the unpaid balance, and further agrees to pay any collection costs incurred to collect the account balance, including court costs, collection fees and attorney's fees of not less than 33% of the unpaid principle and interest.

As an inducement to grant credit, the undersigned agrees to the need for verification of all information herein and authorizes all banks, businesses and persons named on the application to furnish any and all information requested by MDI Corp. or its representatives, by telephone or written request.

Authorized Signature:
Authorized Signature:  
Printed Signature Name:  
Authorized to make purchases? [ ]  YES          [ ] No
Other persons authorized to make purchases on behalf of company:
Name Title
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Copyright 2002 - MDI Corporation.  All rights reserved.


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