COMPLETE LEGAL NAME OF COMPANY OR INDIVIDUAL

MAILING ADDRESS

CITY

STATE

ZIP CODE

PHONE

FAX

WEB SITE

E-MAIL

BILLING ADDRESS

CITY

STATE

BILLING FAX

E-MAIL

LIST PRINCIPALS OF BUSINESS WITH TITLE AND SOCIAL SECURITY NO

NAME

TITLE

SOCIAL SECURITY NO

LIST ANY RELATED COMPANIES

BANK REFERENCES

CREDIT/TRADE REFERENCES

COMPANY NAME
ADDRESS
PHONE NO, FAX NO
CONTACT
COMPANY NAME
ADDRESS
PHONE NO, FAX NO
CONTACT
COMPANY NAME
ADDRESS
PHONE NO, FAX NO
CONTACT

IN CONSIDERATION OF EXTENDING CREDIT TO THE ABOVE NAMED COMPANY OR INDIVIDUAL, I HEREBY CERTIFY AND WARRANT THAT ALL OF THE FACTS AND FIGURES SET FORTH HEREIN ARE CORRECT AND TRUE. WE AGREE TO PAY OUR OBLIGATIONS TO YOU IN ACCORDANCE WITH SUCH TERMS AND CONDITIONS OF PAYMENT AS OUTLINED ON EACH INVOICE SHOULD WE DEFAULT, WE WILL PAY TO YOU A SERVICE CHARGE COMPUTED AT THE RATE OF ONE AND ONE HALF PERCENT PER MONTH ON THE AMOUNT IN DEFAULT. IF YOU PLACE THIS ACCOUNT, AFTER DEFAULT. IN THE HANDS OF A COLLECTION AGENCY OR AN ATTORNEY FOR COLLECTION , WE FURTHER AGREE TO PAY ALL COLLECTION AGENCY AND ATTORNEY FEES.

 

BUSINESS NAME

NAME				TITLE
DATE