If you are prepaying with credit card only, please fill out the portion above Bank References and sign the bottom of the form .
Business Name _________________________________________________ DBA or Division ________________________________________
Mailing Address ________________________________________ City, State, Zip ________________________________________________ Shipping Address_______________________________________ City, State, Zip _________________________________________________ Business Phone ____________________________________________ Business Fax _______________________________________________ Buyer/Order Contact ______________________________________ Buyer Phone ______________________________________________ Buyer email________________________________________________ Website ___________________________________________________ Nature of Business (ex. Specialty Sporting Goods) _______________________________________________________________________ Date Opened __________________
Circle One
Corporation
Partnership
Sole Proprietorship
Non-Profit
Fed Tax ID No._________________________________ Amount of Credit Requested ___________________________________________
Name of Owner/Officer_______________________________ Title ____________________________________________________________ A/P Contact _____________________________ A/P Phone __________________________________ A/P Fax _______________________ Bank Reference: Bank Name___________________________________________________ Phone _________________________________________________ Address ___________________________________________City, State, Zip______________________________________________________ Contact Name ______________________________________________ Account No. ____________________________________________ Dun & Bradstreet No.___________________________________________ Business References: Fax numbers must be up to date as we contact your references by fax. We require 3 favorable references to assign terms. Listing incomplete or incorrect references may result in prepay terms only. Name ___________________________________________Address _____________________________________________________________ City, State, Zip__________________________________ Fax Number __________________________________________________________ Name ___________________________________________ Address_____________________________________________________________ City, State, Zip __________________________________ Fax Number __________________________________________________________ Name ___________________________________________ Address_____________________________________________________________ City, State, Zip __________________________________ Fax Number __________________________________________________________ Name ___________________________________________ Address_____________________________________________________________ City, State, Zip __________________________________ Fax Number __________________________________________________________ Name ___________________________________________ Address_____________________________________________________________ City, State, Zip __________________________________ Fax Number __________________________________________________________ Applicant agrees to financial responsibility, ability and willingness to pay our invoices in accordance with our terms Credit Net 30 Days/$200 minimum opening order. In the event that a delinquent account is placed in the hands of a licensed collector or attorney for collection on the account, in addition to the amount of the delinquent account the applicant shall pay all costs and any reasonable collector's or attorney's fee. A finance charge of 1.5% per month will be assessed on all unpaid balances.* Initial order must be prepaid before qualifying for terms. Applicant certifies that the above information is true and correct. Applicants Authorized Signature _________________________________________________________ Date________________________ Print Name ________________________________________________Title ________________________________________________________