Please provide us
some information about your company.
Just complete the following form and
submit it to us. If you prefer to complete
an Application for Credit off line and
fax or mail it to us, you can download
a form for this by
clicking here. Any information you
include is held in the strictest confidence.
Company Information |
| Date: |
|
Company
Name: |
|
Business
Address |
Street
Address: |
|
City: |
|
State: |
|
Zip
Code: |
|
Phone: |
|
Fax: |
|
Email: |
|
Mailing Address(if
different) |
Street
Address: |
|
City: |
|
State: |
|
Zip
Code: |
|
Parent
Company name (if applicable): |
|
Type
of business started: |
|
Years
at present location: |
|
Year
business started: |
|
Tax
Exempt Certificate number: |
|
Federal
ID number:
|
|
Type
of Organization: |
|
Credit
limit requested: |
|
Has
the Company been involved in any
bankruptcy or insolvency proceedings?: |
No
Yes |
Officers |
First
Officer |
|
Name: |
|
Position: |
|
Home
Address: |
|
City: |
|
State:
| |
Zip
Code: |
|
Second Officer |
|
Name: |
|
Position: |
|
Home
Address: |
|
City: |
|
State: |
|
Zip
Code: |
|
|
|
|
Bank References |
| First Bank |
|
Bank
Name: |
|
Account
Number: |
|
Contact
Person: |
|
Phone
Number: |
|
|
|
Second Bank |
|
Bank
Name: |
|
Account
Number: |
|
Contact
Person: |
|
Phone
Number: |
|
|
|
|
|
Trade References |
| First Reference |
|
Name: |
|
Address: |
|
City: |
|
State: |
|
Phone
Number: |
|
|
|
| Second Reference |
|
Name: |
|
Address: |
|
City: |
|
State: |
|
Phone
Number: |
|
|
|
| Third Reference |
|
Name: |
|
Address: |
|
City: |
|
State: |
|
Phone
Number: |
|
|
|
| Fourth Reference |
|
Name: |
|
Address: |
|
City: |
|
State: |
|
Phone
Number: |
|
|
|
In
making this application for credit, the
customer agrees to pay all
invoices
within 30 days from date of invoice and to
pay a service charge of 3 percent per
month, which is an annual percentage rate
of 18 percent
on all overdue balances. In the event a suit
is necessary to collect any amount, the customer
agrees to pay the Seller's attorney's fees
and costs including attorney's fees for appeal.
By signing this agreement, authorization
is hereby given to the vendors and banks
listed
herein to provide (the company) with all
information necessary to establish credit
with them. I hereby authorize( the company)
to investigate the information presented.
This account will be personally guaranteed
by the persons listed below. |
I
agree: |
Yes
No
|
Name: |
|
Title: |
|
Date: |
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