APPLICATION FOR CREDIT

Firm Name: _________________________________ Contact person: ____________________________

Address: _______________________________________________________________

City: ___________________________________State: __________Zip: _____________________

Phone: _____________________ Fax: _____________________ Email: ______________________________

Principals name: _________________________________________ ASI #___________________

Federal ID # or SS # : _____________________________ D&B # _________________________

Bank Reference

Name: ______________________________________________ Account #: __________________________

Address: _______________________________________________________________

City: _____________________________ State: __________________ Zip: __________________

Phone: ___________________________ Date account opened: ______________________

Trade References

Firm name: ____________________________________________ Phone: ___________________________

The undersigned herby agrees that should a credit account be opened, and in the event of default in the payment of any amount due, and if such account is submitted to a collection authority, to pay an additional charge equal to the cost of collection including court costs.

The undersigned individual who is either a principal of the credit applicant or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.

Company: ________________________________________ Date: _____________________

Signature: ________________________________________ Title: ______________________

Please print your name: _______________________________________________

Payment Terms: Net 30 days from date of shipment. A monthly late payment charge of 1.5% is applied to any balance unpaid 30 days after due date.

All orders are subject to credit approval by our credit department and will not be processed until approved.
We accept Visa, Mastercard, American Express and Discover.
If paying by credit card, payment must be made at time of order.

Thank You. We look forward to doing business with you. Please sign & FAX back to (847)-301-7985