Fill and Sign the Indebtedness of the Purchaser Hereon Stated Form

Business Credit Application Date: Customer or Company Name: Mailing Address: Street Address: City & State: Zip Code Business Phone: Home Phone Kind of Business: Incorporated: Partnership Individual Amount of Credit Requested Special Invoicing Procedure Principal Owner(s) or Officer(s) Are: NAME SOC. SEC. # TITLE RESIDENCE ADDRESS PHONE Attorney’s Name Name and Address of Nearest Relative Not Living with You Bank Account Numbers Loan Officer Other Accounts: Loans From Loan Officer Individual Information Employment Years Age Spouse’s Name Credit References Address Dun & Bradstreet Number Bonded Yes No Bonding Company Address City/ State/ Zip In 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 unde rsigned 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 exte nsion of credit to the principal, the undersigned, whether officer, partner, agent, or otherwise agree that by execution he reof or behalf of the principal he or they is/ are personally liable, jointly and severally with the princ ipal, as a guarantor(s) for the payment of all indebtedness or liabilities incurred pursuant to this agreement. Demand for payment and not ice of indebtedness and default are expressly waived. In the event of default, each of the undersigned hereby assign to selle r a sufficient portion of his homestead exemption to which he may be entitled under laws of the state of his resi dence 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 i ncurred prior to the actual receipt by seller of such notice of revocation 4. It is agreed that the sales, whether invoiced to the purchaser in his or its individua l, 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 shal l 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 rec eived 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 prom ptly 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 m aterial which might have been determined by a prompt and diligent inspection thereof. 9. Seller retains title and security interest in all appliances until pa id 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 informa tion to __________________________________. NOTICE: DO NOT SIGN AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS THEREOF. CORPORATION NAME: INDIVIDUALS & PARTNERSHIPS SIGN HERE: By: President Individual Guarantor By: Secretary- Treasurer Individual Guarantor CORPORATE OFFICERS MUST ALSO SIGN AS INDIVIDUAL GUARANTORS AUTHORIZED SIGNATURES FOR PURCHASE ON ACCOUNT Recommended By: Store Manager