Salesman # __________

Date: __________

Account Application
INSTRUCTIONS:
THIS APPLICATION MUST BE COMPLETED IN FULL AND APPROVED PRIOR TO THE EXTENSION OF ANY CREDIT.
Business Information: Date:

Check One: ☐Individual/Proprietorship ☐Partnership ☐Corporation

*Business / Corporation Name Business/Corp Name

Doing Business As DBA Name
Years In Business Years Date Incorporated

Type Of Business Type of Business State Resale# State Resale #

Contact Name Contact Name Business Phone #Business Phone#

Federal Tax ID#Federal Tax ID # Fax # Fax #

Name Of Parent Or Affiliate Company Name of Parent or Affiliate Company

E-Mail: E-Mail address
Account Payable Name Account Payable Contact Acct Payable Phone Acct Payayble Phone #
Acct Payable Email Account Payable Email

*Shipping Address
Street Address Shipping Street Address
City & State City & State Zip Code Zip Code

*Billing Address (If different that Shipping Address)

Street Address Street Address
City & State City & State Zip Code Zip Code

Name Of Bank Name of Bank Branch Branch

Telephone Number Telephone # Bank Address Bank Address
City & State City and State Zip Code Zip Code
Bank Contact Name Bank Contact Name Bank Account Number Account #
Name Of Bank Account Name of Bank Account

Accounts Receivable:
Are your accounts receivable currently pledged? ☐Yes ☐ No
If yes, please give the name, address, and telephone number for the secured party:
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Trade References: (Do not include utilities or credit card accounts)

Name Name Contact Name Contact Name

Telephone Telephone # Address Address
City, State, Zip City, State, Zip Email Email

Name Name Contact Name Contact Name

Telephone Telephone # Address Address
City, State, Zip City, State, Zip Email Email

Name Name Contact Name Contact Name

Telephone Telephone # Address Address
City, State, Zip City, State, Zip Email Email

Name Name Contact Name Contact Name

Telephone Telephone # Address Address
City, State, Zip City, State, Zip Email Email

*Personal Information:
Principal Name Principal Name Title Title
Social Sec # Social Sec. # Home Address Home Address
City & State City & State Zip Code Zip Code
Home Telephone # Home Telephone # Have you ever filed Bankruptcy? ☐Yes ☐No

*Ownership:
Name (s) Title(s) & Address of Owner(s) Percentage Of SS #
&/or Officer(s): Ownership
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The person or persons signing this agreement must correctly indicate in writing after his or her signature, the legal capacity of the person or persons signing. Any
person signing this agreement agrees that he or she will be personally, individually, and if married, his or her marital community will be liable as a party to all terms
and conditions of this agreement and will pay for the reasonable collection and / or attorney fees in addition to other sums due. The undersigned certifies that the
above information is correct. Applicant authorized PENS ETC. to obtain credit and financial information concerning the applicant and all principles at any time and
from any source. Applicant fully understands credit terms and agrees to prompt payment in consideration of extended credit.

* Company Name Company Name

Signature ____________________________________________________ Date Date

Print Name And Title _______________________________________________________________

Must be signed by owner, partner or corporate officer

Updated 12/1/20 6895 W. Frye Rd. - Chandler, AZ 85226 Ph: 480-831-9600 - Toll Free: 800-423-4165
Fax: 480-831-9601 - Toll Free: 800-423-4166