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Supplier Application Form

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fabiansol137
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29 views2 pages

Supplier Application Form

Uploaded by

fabiansol137
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Belize Telemedia Ltd.

1 St. Thomas
Street Tel: 501-
223-1800
Website: www.belizetelemedia.net

Supplier Application Form

Section I - Company Information

Company Name:
Physical Address:
Mailing Address:
City: State Zip Code: Phone #: Fax #:

Type of Business: □Corporation □Partnership* □Sole Proprietorship* □LLC □LLP

*Full Name of Owner/Partners:


Number of years in business:

Name of President if a Corporation: Phone #:

Name & Title of Company Representative:


Direct E-mail address of Company Representative:
Details on Services or Goods your company supplies:

Payment Terms Offered:

Section II – Financial Information

Kindly provide us with the following information:

(a) Certified/audited financial information i.e. Balance Sheet and Income Statement, copy of your signed income
tax return, Annual Report to Shareholders
(b) Current and valid copy of certificate of incorporation/business certificate or national equivalent

(c) Banking Information

Intermediary Banking Information

Bank Name: Branch:


Intermediary account: Swift Code:
ABA Routing #: IBAN #:
Bank Contact Name: Phone #:
Bank Address:

Beneficiary Banking Information

Bank Name: Branch:


Intermediary account: Swift Code:
ABA Routing #: IBAN #:
Bank Contact Name: Phone #:
Bank Address:
Belize Telemedia Ltd.
1 St. Thomas
Street Tel: 501-
223-1800
Website: www.belizetelemedia.net

(d) Accounting Department Information

Accounts Payable Contact A/P Phone #:


A/P Address (If different from other addresses):
A/P E-Mail Addresses:

Section III – Trade References:

• Name: How Long:


Address: City, State, Zip:
Contact Name: Email address:
Phone #: Fax #:

• Name: How Long:


Address: City, State, Zip:
Contact Name: Email address:
Phone #: Fax #:

As an authorized representative of the listed company signer agrees to:

⮚ The release of financial information, solely for the purpose of establishing business relations.
⮚ The undersigned certifies the above information is correct and authorizes the above indicated bank and business
references to verify said information.

Signed Title Date


Signature must be” That of the owner or an officer of the company”

Print Name

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