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General
Information
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Firm
Name:
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Billing
Address:
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Business
Phone:
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Fax
Number:
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A/P
Contact:
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Shipping
Address:
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Type
of Business:
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Physician
Hospital
Other
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Date
Business
Established:
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Tax
I.D. Number:
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Ownership:
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Principal
Owner(s) or Officer(s)
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Name
(1):
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Title:
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Address:
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Phone:
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S.S.#:
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Name
(2):
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Title:
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Address:
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Phone:
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S.S.#:
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Finance
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Bank:
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Account
Number :
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Branch/Location::
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Phone
Number :
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Contact:
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Trade
References
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Supplier
#1:
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Phone
Number:
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Contact:
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Address:
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Bank:
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Account
Number:
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Supplier
#2:
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Phone
Number:
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Contact:
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Address:
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Bank:
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Account
Number:
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Supplier
#3:
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Phone
Number:
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Contact:
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Address:
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Bank:
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Account
Number:
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Ordering
Information
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Purchase
order
required:
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Yes
No
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Special invoice
requirement:
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Persons
authorized to
charge on account
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Tax
exempt:
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No
Yes
-- Tax Exempt Number
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Do
You Own Real Estate?
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Yes
No
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Parcel
1 Address:
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City:
State:
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Parcel
2 Address:
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City:
State:
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Owned
or Leased Vehicles
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Vehicle
#1:
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Leased
Owned
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Make::
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Model:
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Lessee
or lender:
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Address:
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Vehicle
#2:
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Leased
Owned
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Make::
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Model:
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Lessee
or lender:
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Address:
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Company
Guaranty
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Buyer hereby authorizes Seller
to check Buyer's bank and credit
references to obtain such information
as may be required to approve
this application for credit.
Buyer agrees that this application
for credit shall remain seller's
property and will be included
in Buyer's credit file. In the
consideration of the granting
and extension of credit by Seller
to Buyer, it is hereby agrees
that the Buyer will pay all
sums when due. In the event
of non-payment, the undersigned
does hereby agree to pay in
addition to the principal amount
due, all collection charges
incurred by Seller including
charges made by a collection
agent up to but not exceeding
30% of the principal balance
due and in the event of suit,
reasonable attorney's fees and
court costs. The Buyer further
agrees to pay interest at the
rate of 18% per annum commencing
on the first day following the
due date for any monies owning.
In the event of breach of the
above contract or if Buyer exceeds
the credit limit, the Seller
reserves the right to change
credit terms.
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Company
Name:
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By:
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Title:
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Date:
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Personal
Guaranty
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In
consideration of the extension
of credit or increase in credit
limit by the Seller, herein
to Buyer herein, I/we do jointly
and severally personally guarantee
to pay and be responsible for
payment of all sums, balances
and accounts due Seller by Buyer,
including collection charges
and/or attorney's fees. This
shall be an open and continuing
guarantee and shall continue
in force nothwithstanding any
change in the form of such indebtedness,
or renewals or extensions granted
by Seller, without obtaining
any consent thereto, and until
expressly revoked by written
notice from me/us to Seller,
any such revocation shall not
in any manner affect my/our
liability as to any indebtedness
existing prior thereto. I/we
do hereby waive notice of the
acceptance of this agreement,
notice of default or non-payment
and waive action required by
any statute, against the buyer.
No delay on Seller's part in
exercising any right hereunder,
or taking any action to collect
or enforce payment of any obligation
hereby guaranteed, either as
against the Buyer or any other
person primarily or secondarily
liable with the Buyer, shall
operate as a waiver of any such
right or in any manner prejudiced
Seller's right against me/us.
I/we agree that in the event
of any default at any time by
said Buyer, Seller shall be
entitled to look to me/us immediately
for full payment without prior
demand or notice.
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Name:
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Home
Address:
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City:
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Phone
Number:
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Date:
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I
agree to the above.
I
do not agree to the above.
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