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Credit application

CREDIT APPLICATION

(xxx) xxx-xxxx
(xxx) xxx-xxxx

(xxx) xxx-xxxx
(xxx) xxx-xxxx
Full Name and Title of Person Requesting Credit:
E-mail Address:
Requested Credit Limit:
Sales Manager:
Authorized Purchasing Agent:
What do you estimated your monthly purchases to be?:
Type of Organization:
Material Purchased For:
Type of Business:
Resale Certificate #:
State Issued:
Number of Years in Business:
Listed in Dun & Bradstreet?YesNo
if Yes, List D&B Number:

PRINCIPAL OWNER:

(xxx) xxx-xxxx
(xxx) xxx-xxxx
If there are additional owners please enter their full name, full address and phone numbers in the field below:

BANK REFERENCES:

(xxx) xxx-xxxx
(xxx) xxx-xxxx

TRADE REFERENCES:

Please list references (USA refrences preferred):

Reference #1

(xxx) xxx-xxxx
(xxx) xxx-xxxx

Reference #2

(xxx) xxx-xxxx
(xxx) xxx-xxxx

Reference #3

(xxx) xxx-xxxx
(xxx) xxx-xxxx

How did you hear about SJE-Rhombus?

I hereby certify that all information provided is true and authorize SJE-Rhombus, CSI Controls, Primex, and/or ICS Healy-Ruff, to contact trade and bank references for normal credit information. The information being furnished to SJE-Rhombus, CSI Controls, Primex, and/or ICS Healy-Ruff is for the purpose of extension of credit. The undersigned authorizes the above listed references to provide SJE-Rhombus, CSI Controls, Primex, and/or ICS HealyRuff with information regarding account history. This authorization may include, but is not limited to, obtaining a credit report. A service charge of 1 Y, % per month may be incurred on all bills remaining unpaid after 30 days past agreed upon credit terms. If this account is placed in the office of a collection agency or attorney for collections, the undersigned shall pay an amount equal to 25% of the unpaid principal and interest as a collection fee, the amount of which the undersigned agrees is reasonable. This is to certify that I am a principal in the above business and in consideration for the extension of credit; I do personally guarantee payment of any and all invoices which remain unpaid for a period of thirty (30) days or longer past agreed upon credit terms. This applies to the above business, and/or company, and/or all affiliate companies, and/or successor companies.

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