Credit application form

Credit application form

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Tax Exempt Certificate Required?     State:

   or  $      $

Please enter at least one principal.
Full Name Social Security Number Home Address City State Zipcode

Please provide three business references.
Name of Business Contact Name Full Address Phone

I (we) promise to pay my account in full within ten days after your statement is received.* If, however, this account is not paid as agreed, I (we) agree to pay in addition to the foregoing, a reasonable attorney's fee, or if this account is placed in the hands of a collection agency, I (we) acknowledge that you will be damaged thereby to the extent of the collection charge against you and I (we) therefore agree to pay to you, as liquidated damages, an amount equal to the amount charged you on said collection by said collection agency, not exceeding, however, fifty percent of the amount unpaid thereon, and also a reasonable attorney's fee.

For value received each and every party who signs this agreement or becomes liable either now or hereafter for the payment of this agreement severally waives presentment, demand, protest, and notice of non-payment hereof, binds himself hereon as the principal and not as surety and agrees to remain bound hereon notwithstanding any extension that may be made to any party liable hereon. At the option of this holder hereof, the venue of said suit may be laid in the county of the residence of the holder.

You are herby authorized to contact any or all of the above references regarding our credit standing. I understand the above stated credit terms and policy as stated.


By checking this box and clicking Submit Application, below, I certify that I have read, fully understand and accept all the terms of the foregoing Application Statement, and have read and agree to all the terms and conditions of sale: