Company Name

DBA (if different)

Contact Person

Address

Phone

Fax

Federal Tax ID or Social Security Number

Type of Business

No. of Employees

Date business established

Corporation

•   Yes

State of Corporation

Names, titles, and addresses of your three chief corporate officers

Name and address of your resident agent – If applicable

Partners

•   Yes

Names and addresses of the partners

SOLE PROPRIETORSHIP

•   Yes

Are you sales tax exempt?

•    Yes
•    No

Have you ever had credit with us before?

•    Yes
•    No

If yes, under what name?

Authorized purchasers

Purchase order required?

•    Yes
•    No

Trade References

Reference #1

Name (Reference #1)

Address (Reference #1)

Phone (Reference #1)

Reference #2

Name (Reference #2)

Address (Reference #2)

Phone (Reference #2)

Reference #3

Name (Reference #3)

Address (Reference #3)

Phone (Reference #3)

Bank References

Bank #1

Account #1

Phone (Bank #1)

Contact Person (Bank #1)

Name of Bank (Bank #1)

Address (Bank #1)

Bank #2

Account #2

Phone (Bank #2)

Contact Person (Bank #2)

Name of Bank #2

Address (Bank #2)

Printed Name

Title

Date

GENERAL TERMS AND CONDITIONS AND PERSONAL GUARANTEE

1. You may take the 2% discount as indicated on the bill if you pay the invoice by the 10th day outstanding.
2. All bills become payable in full on the 11th day of outstanding and if not paid in 30 days are considered past due.
3. A service charge of 2% per month will be added to all amounts billed if not paid by the end of the month.
4. No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.
5. PERSONAL GUARANTEE: If the credit customer is a corporation, then those signing this application, whether signing as an officer or not, personally guarantee payment for all items purchased on credit by the corporation.