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| Company Information: Company (Legal) Name: ___________________________________________________________________________ Company Name to be Used on Account: _______________________________________________________________ Street Address: ___________________________________________________________________________________ City: __________________________________________________ State: __________ Zip Code: _______________ Office Phone: ________________________ Mobile Phone: _______________________ Fax: ___________________ A/P Contact: __________________________________________________ Phone Number: ____________________ E-mail Address: __________________________________________________________________________________ Purchase Order Required? (Check One) __YES __NO Requested Credit Line: ________________________ Check One: __Proprietorship __Partnership __Corporation __Other (Specify): ______________ Date Established: _________________ State Incorporated In: __________ Federal ID #: _______________________ If applicable, sales tax exemption certificate must be attached. |
| NAMES OF ALL OWNERS, PARTNERS, MEMBERS, OR OFFICERS: |
| Name:
Title:
Phone
#: Social
Security #: 1._____________________________________________________________________________________________ 2._____________________________________________________________________________________________ 3._____________________________________________________________________________________________ |
| BANK REFERENCES: |
| Type
of Account:
Account #:
Name of Bank: Bank
Contact: Phone
#: Savings ________________________________________________________________________________________ Checking _______________________________________________________________________________________ Commercial Loan ________________________________________________________________________________ |
| BUSINESS CREDIT REFERENCES (UNSECURED): |
| Trade Reference
Name:
Phone
#: Fax
#:
Account
#: |
| CREDIT TERMS AND CONDITIONS |
The
undersigned Buyer hereby certifies that the undersigned accepts the terms
of the Document and that the undersigned has the authority to bind the
Buyer. In consideration of the extension of credit to the Buyer’s
account, the Buyer and the undersigned personal guarantors individually,
jointly, and severally guarantee full and complete payment of account.
The Buyer acknowledges that the Document shall remain in full force and
effect unless otherwise amended, rescinded, or terminated by County Form
& Supply, Inc., (the Seller). The Buyer also gives the Seller the
right to investigate all bank and business references as well as all personal
credit history provided by the Buyer in its completion of these applications.
The Buyer also agrees to pay all collections costs, attorneys fees, court
costs, and other legal fees incurred by the Seller to collect on any account
which may be established. This agreement is deemed to have been made and
entered into in the State of Missouri and shall be construed in accordance
with the laws of the State of Missouri. The undersigned Buyer hereby consents
to personal jurisdiction in the State of Missouri and venue in St. Louis
County, Missouri. The information provided herein is true and correct,
and the Buyer understands that any false information may result in cancellation
of any account which may be established. |
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