Fill and Sign the Demand for Payment and Notice of Indebtedness and Default Form

Business Credit Application Date:Customer or Company Name: Mailing Address:Street Address:City & State:Zip CodeBusiness Phone:Home PhoneKind of Business:Incorporated: Partnership Individual Amount of Credit RequestedSpecial Invoicing ProcedurePrincipal Owner(s) or Officer(s) Are: NAME SOC. SEC. # TITLE RESIDENCE ADDRESS PHONE Attorney’s NameName and Address of Nearest Relative Not Living with YouBankAccount NumbersLoan OfficerOther Accounts:Loans FromLoan OfficerIndividual InformationEmploymentYearsAgeSpouse’s NameCredit ReferencesAddressDun & Bradstreet NumberBonded Yes No Bonding CompanyAddressCity/ State/ ZipIn consideration of the extension of credit by ______________________________, the undersigned purchaser hereby agrees that the terms and conditions of all sales are as follows:1.Terms of sale are: Net Due 10th of each month following purchases. Invoices not paid within such time are past due and subject to service charge of __________ percent per month (effective rate ___________ percent per annum).2.Should this account upon default, be collected by or through an attorney at law, the undersigned agrees to pay reasonable attorney’s fees in addition to the principal indebtedness and interest thereon.3.Should purchaser be a corporation or partnership, for good and valuable consideration, including the extension of credit to the principal, the undersigned, whether officer, partner, agent, or otherwise agree that by execution hereof or behalf of the principal he or they is/ are personally liable, jointly and severally with the principal, as a guarantor(s) for the payment of all indebtedness or liabilities incurred pursuant to this agreement. Demand for payment and notice of indebtedness and default are expressly waived. In the event of default, each of the undersigned hereby assign to seller a sufficient portion of his homestead exemption to which he may be entitled under laws of the state of his residence to pay his obligation hereunder. The terms and conditions hereof and the guarantee herein given shall continue in full force and effect until such time as the seller, _______________________________, shall receive from the undersigned written notice of revocation, and such revocation shall not in any way relieve the undersigned from indebtedness or liability incurred prior to the actual receipt by seller of such notice of revocation4.It is agreed that the sales, whether invoiced to the purchaser in his or its individual, corporate or partnership name or in any trade name or in the name of any subsidiary company or in the name of any officer or agent, shall nevertheless be an indebtedness of the purchaser hereon stated. 5.Purchaser agrees to examine all invoices and statements promptly upon receipt and to notify seller immediately of any failure of delivery, shortage, discrepancy, or error, and further agrees that such invoice or statement shall be presumed correct unless he or it shall notify seller in writing of such failure of delivery, shortage, discrepancy, or error within thirty (30) days of his or its receipt of such invoice or statement, which shall be presumed to have been received on or before the fifteenth (15th ) day of the month succeeding purchases.6. Seller disclaims all warranties, express or implied, to the extent permitted.7. Purchaser agrees to immediately examine shipment and agrees to notify seller promptly of any errors in shipment and of any defective material supplied.8. Use of material shall constitute a waiver of any error in shipment or defect in material which might have been determined by a prompt and diligent inspection thereof.9. Seller retains title and security interest in all appliances until paid for, and in all materials until such shall lose its character as personal property.I/We authorize any government agency, be it federal, state, or county to furnish information to __________________________________.NOTICE: DO NOT SIGN AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS THEREOF.CORPORATION NAME:INDIVIDUALS & PARTNERSHIPS SIGN HERE:By:PresidentIndividual GuarantorBy:Secretary- TreasurerIndividual GuarantorCORPORATE OFFICERS MUST ALSO SIGN AS INDIVIDUAL GUARANTORSAUTHORIZED SIGNATURES FOR PURCHASE ON ACCOUNTRecommended By: Store Manager