| 1. Company Name and Address |
_________________________________________________ |
| |
_________________________________________________ |
| |
_________________________________________________ |
| |
|
| 2. Phone |
( ) __________________ Fax ( ) ___________________ |
| 3. Federal Tax ID or Social Security No. |
_________________________________________________ |
| 4. Type of Business |
__________________________ |
No. of Employees |
__________________________ |
|
| 5. Date Business Established |
__________________________ |
| 6. Types of Products You Will Purchase |
_________________________________________________ |
| 7. Amount of Credit Requested $ |
_________________________________________________ |
| 8. Check which is applicable to you: |
|
| 9. State where your company was organized : |
_________________________________________________ |
| 10. Have you or any of your affiliates ever had credit with us before or purchased from us before? Yes ___ No ___ |
| If yes, under what name? |
_________________________________________________ |
| 11. Name or title of persons authorized to act on your behalf : _________________________________________________ |
| 12. Trade References |
| Reference #1 Name and Address : |
_________________________________________________ |
| |
_________________________________________________ |
| |
_________________________________________________ |
| |
Phone ( ) ________________________________________ |
| Reference #2 Name and Address : |
_________________________________________________ |
| |
_________________________________________________ |
| |
_________________________________________________ |
| |
Phone ( ) ________________________________________ |
| Reference #3 Name and Address : |
_________________________________________________ |
| |
_________________________________________________ |
| |
_________________________________________________ |
| |
Phone ( ) ________________________________________ |
|
| 13. Bank References |
| Bank #1 Account # |
__________________________ |
Phone ( ) |
__________________________ |
|
| |
| Contact Person |
____________________________________________________________ |
| Name of Bank |
____________________________________________________________ |
| Address |
____________________________________________________________ |
|
| Bank #2 Account # |
__________________________ |
Phone ( ) |
__________________________ |
|
| |
| Contact Person |
____________________________________________________________ |
| Name of Bank |
____________________________________________________________ |
| Address |
____________________________________________________________ |
|
| 14. Financial Information about your Company : |
| |
| Assets: |
$______________________________________________________ |
| Liabilities: |
$______________________________________________________ |
Approximate Annual
Net Income: |
$______________________________________________________ |
|
| 15. Have you or your officers or affiliates ever filed a petition in bankruptcy? __________________________ |
| 16. Are you subject to any litigation? __________________________ |
| If so, describe here: _________________________________________________________________________________________ |
| _________________________________________________________________________________________________________ |
| 17. Are you current in meeting your other financial obligations? ________________________________________________________ |
| |
We declare that the above information is true, correct and complete and is given to induce the Company to extend credit. We authorize the Company to make such credit investigation as the Company sees fit, including contacting the above trade references and banks and obtaining credit reports. We authorize all trade references, banks and credit reporting agencies to disclose to the Company any and all information concerning the financial and credit history of my company and myself: |
| I have read the terms and conditions stated below and agree to all of those terms and conditions |
| Name of Company : |
________________________________________________________ |
| Authorized Signature : |
________________________________________________________ |
| Printed Name : |
________________________________________________________ |
| Title: |
____________________ |
Date: |
_________________________________________________ |
|
GENERAL TERMS AND CONDITIONS
1. All bills become payable in full ___ days after receipt. If not paid by such time, bills are considered past due.
2. A service charge of 5% per monthly will be added to all amounts billed if not paid by the end of the month, together with interest at the rate of 1˝% per month. |
| |
