DISTRIBUTOR CREDIT APPLICATION

AND

PURCHASE AGREEMENT

Company Name

Street Address

E-Mail

Mailing Address

City, State, ZIP
Telephone

Fax

Description of Business

Resale Tax Number

State

Business Structure Corporation Partnership Sole Proprietorship
In Business Since No. Employees

Monthly Credit Req'd.

If Subsidiary or Branch, Parent Company Name
 

Address of Parent Company

Company Principals
 

1 Name

Title

Address

 

2 Name

Title

Address

 

3 Name

Title

Address

Trade References
1 Name

Mailing Address

City, State, ZIP

Telephone/FAX

 

2 Name

Mailing Address

City, State, ZIP

Telephone/FAX

 

3 Name

Mailing Address

City, State, Zip

Telephone/FAX

Financial Reference
Bank Name

Street or P.O. Box No.

City, State & Zip

Telephone

Account Number

Contact

Purchasing Terms and Conditions
1 The undersigned certifies all information provided is correct and authorizes the bank and trade reference listed to release the information necessary to establish credit at Central States Business Forms.
2. The undersigned acknowledges Central States terms of 2% 15 days; Net 30 and that a service charge will be applied to accounts over 30 days old. These service charges will accrue at the rate of 1 1/2% per month (18% per annum or the maximum allowed by law).
3. The undersigned acknowledges that goods and/or services purchased from Central States Business Forms are not payable in installments, but are payable in full as stated herein.
4. In the event that collection of account requires services of a collection agency or an attorney, by suit or otherwise, applicant agrees to pay all collection fees and/or attorney's fees and cost of collection.
5. Orders are produced under the industry's general trade practices and customs.
 

 

I, , being duly authorized representative of the company named above, certify that the above is true. I further authorize all of the organizations listed above as trade and bank references to give Central States any information it deems necessary to evaluate this application for credit and authorize Central States to request same.

Authorized Signature ________________________________________

Title

Date

Please fill out form, print, sign and fax to: 918-534-4286