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CREDIT APPLICATION 

 

Company Name: _____________________________________________________

Contact: _____________________________________________________

Billing Address: _____________________________________________________

City: ________________________ State: _____________ Zip Code: ____________

Shipping Address: _____________________________________________________

City: ________________________ State: _____________ Zip Code: ____________

Phone: _________________________ FAX: __________________________

E-mail: _____________________________

Type of Business: ____________________________ In Business Since: __________

Form of Business: [ ] Corporation [ ] LLC [ ] Partnership [ ] Sole Proprietor

Is a Purchase Order required? _________

Name of individual with authorization: ____________________________________

If it is to be a blanket PO, please list the number and expiration date.

Number ____________________ Expiration Date ________________

To whose attention should invoices be sent? __________________________________

Is your work taxable? ____ If not, please attach signed certificate and list your tax exempt or resellers number: ____________________________________________

If you which to pay by credit card, please provide information below:

VISA Card Number __________________________________ Exp. Date __________

MasterCard Number __________________________________ Exp. Date __________

American Express Card Number _________________________ Exp. Date _________

Bank References (please list name and address of local banks):

_____________________________________________________

_____________________________________________________

_____________________________________________________

Trade References (Please list name, address, phone number, and account number of three references. Do not list credit cards.)

_____________________________________________________

_____________________________________________________

_____________________________________________________

Our terms are net 30 days. Accounts not paid in this time frame will be charged 1.5% interest rate per month and future orders will be on a C.O.D. basis until the account is current. Should collection or legal action be required to collect past dues, fees for such action will be added to your account.

Print Name: ___________________________ Title: __________________________

Signed by: _______________________________ Date: ___________________

 

 

Warning:

These forms are provided AS IS. They may not be any good. Even if they are good in one jurisdiction, they may not work in another. And the facts of your situation may make these forms inappropriate for you. They are for informational purposes only, and you should consult an attorney before using them.

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