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Customer Name*
Federal ID# or SS#*
 
* = Required
Billing Address*

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Phone*
Fax*
   
Requested Credit Amount
Accounts Payable Contact*
Purchasing Agent
Sales Tax Exemption Number (if applicable)

Banking References
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Contact*
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Contact

Owner/Partner Information
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Home Address
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Business Trade References We May Contact
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I understand that I will not be sent a monthly statement and the invoice I receive will be the only notice to me that payment is due. I/We also understand that a service charge of 1-1/2% per month of the maximum amount allowed by law will be assessed against our account if I/We do not pay within our terms of Net 30 Days. Unless other terms are agreed to.

I (we) certify that the above information is true, complete, accurate and authorized verification. I (we) understand that the information furnished you on this page is for the purpose of obtaining credit from your firm and that I am (we are) authorized, in my (our) capacity, bind my (our) firm accordingly. It is agreed that the account of the undersigned will be paid in accordance with the terms stated on the invoice, unless other arrangements have been made. In the event that any dispute arises between the parties with respect to this agreement and such matter is referred to an attorney for resolution, the prevailing party will be entitled to recover from the losing party all costs and attorney fees incurred by the prevailing party. It is understood the above named corporation offices or all above named partners will be held personally responsible for all costs previously mentioned in the event that the corporation or partnership cannot pay or is liquidated.

I/We understand and acknowledge that our application will be used to evaluate our stability and credit. In addition some or all of this information may be used with a Consumer Reporting Agency. This information will be kept confidential and used only by this office.

Authorized By:
Name
Title
Date
11/13/2018
 

(Owner, Partner, or Authorized Party) *

Release Authorization:
I authorize above named references to release any information needed to Stephens Rock & Dirt, Inc.

Name
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