CREDIT
APPLICATION AND AGREEMENT
(Confidential
Information for Credit Verification)
Date____________________
Company Name___________________________________ Phone______________________
Fax_______________________________ E-Mail Address_____________________________
Billing Address________________________________________________________________
Shipping Address______________________________________________________________
NAMES
OF PRINCIPALS OF FIRM:
President______________________________ Treasurer_____________________________
Vice President__________________________ Controller_____________________________
( ) Corporation ( ) Partnership ( ) Single Ownership
Division
of ( ) Parent
Company__________________________________________
Subsidiary of ( )
Address_____________________________________________________________________
Type of Business______________________________________________________________
Number of Employees____________________ How Long in Business____________________
Credit Line Desired per Month $__________________________________________________
Do you use Purchase Orders________________ Purchasing Agent_____________________
Is Merchandise for Resale__________________ Resale Number________________________
We, the undersigned,
hereby authorize the following credit references to disclose all details
necessary to
enable __________________________________________ to establish an open
account.
BANK REFERENCES:
Name________________________________ Branch_________________________________
Address_____________________________________________________________________
Phone_____________________________ Account__________________________________
Assets Pledged? Yes ( ) No ( ) With Whom________________________________________
TRADE
CREDIT REFERENCES:
1. Name__________________________________________ Phone_____________________
Address_____________________________________________________________________
2. Name__________________________________________ Phone_____________________
Address_____________________________________________________________________
3. Name__________________________________________ Phone_____________________
Address_____________________________________________________________________
This Credit Application and Agreement is submitted by Buyer to ____________________
(Seller) to obtain trade credit. Buyer agrees to make payment in full
to Seller for all amounts due according to Seller’s invoice(s). (Buyer
also agrees to pay to Seller, as interest, an amount equal to 1 1/2% per
month or the maximum provided by law (whichever is less) for invoice amounts
that are past due.)
Dated at_______________, as of this_______________day of ___________,
20____
Buyer________________________________________
(Authorized Signature)
_______________________________________
(Title)