Mid Atlantic Data Systems, Inc. 845D Quince Orchard Boulevard, Gaithersburg, MD 20878 Voice: (301) 590-0666, FAX: (301) 417-9737 C R E D I T   A P P L I C A T I O N All fields are required to be filled out for the application to be accepted. Company Information: Company Name  Address  City/State/Zip        Phone  Trade References (3 Required): Name  Address  City/State/Zip        Phone  Account #  Name  Address  City/State/Zip        Phone  Account #  Name  Address  City/State/Zip        Phone  Account #  Requested Line Of Credit $: Financial Authorization to Release Confidential Information To Financial Institution From Customer Bank Reference: Name  Address  City/State/Zip        Phone  Checking Account# Savings Account# Please accept this as authorization to release the following information to Mid Atlantic for the purpose of extending credit I do hereby certify that all information contained herein is true and complete to the best of my knowledge. Title: Date: Please Print and fax page to 301-417-9737