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Application for Credit
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" indicates required fields
Name of Applicant
*
First
Last
D.B.A.
Phone
*
Fax
Email
*
Mailing Address
*
Street Address
Address Line 2
City
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District of Columbia
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Utah
U.S. Virgin Islands
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Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Shipping Address (if Different
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Name of Purchasers
*
A/P Contact
*
Tax Exemption Number
Please upload proof of your tax exempt status.
Max. file size: 50 MB.
Date Business Started
*
Amount of Credit Requested
*
Credit References
*
Please provide at least 3 credit references.
Company Name
Mailing Address
Phone
Fax
Contact
Add
Remove
Bank Reference: Name
*
Bank Reference: Address
*
Bank Reference: Phone
*
Bank Reference: Contact
*
Driver License
*
Please upload an image of your driver license.
Max. file size: 50 MB.
Consent
*
I agree to the statement below.
I understand that the information furnished to you on the previous page is for obtaining credit approval from your firm. I fully understand your credit terms of NET 30 DAYS and agree to your payment terms. That all accounts or monies due shall be due and payable at your business. That all past accounts, notes, judgment, or legal fees may automatically draw interest at the rate of 10 percent (%) per annum. In the event of a returned check, a $35.00 fee will be charged. I am authorized, in my capacity, to bind my firm accordingly.
I understand that all credit card purchases could potentially be charged a 3% transaction fee unless prior approval has been granted.
Name
*
First
Last
Title
*
Signature
*
Personal Guaranty
*
I agree to the statement below.
In consideration of credit being extended to the firm, I personally guarantee all indebtedness hereunder. I further agree that this guaranty is an absolute, completed and continuing one and no notice of the indebtedness or any extension of credit already or hereafter contracted by, or extending need be given, the terms may be re-arranged, extended and/or renewed without notice to me. That I will, within 10 days from the date of notice that the account is past due, pay the amount due.
Name
*
First
Last
Home Phone
*
Social Security Number
*
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Signature
*
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