Fill and Sign the Indiana Individual Credit Application Form

Individual Credit Application Date: Customer Name: Mailing Address: Street Address: City & State: Zip Code Business Phone: Home Phone Persons to use this account Are: NAME SOC. SEC. # RELATIONSHIP ADDRESS PHONE Name and Address of Nearest Relative Not Living with You Bank Account Numbers Loan Officer Other Accounts: Loans From Loan Officer Employment Years Age Spouse’s Name Credit References Address In consideration of the extension of credit by ______________________________, the undersigned purchaser h ereby agrees that the terms and conditions of all sales are as follows: 1. Terms of sale are: Net Due 10 th 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 attor ney at law, the undersigned agrees to pay reasonable attorney’s fees in addition to the principal indebtedn ess and interest thereon. 3. Purchaser agrees to examine all invoices and statements promptly upon rec eipt and to notify seller immediately of any failure of delivery, shortage, discrepancy, or error, and further agrees tha t such invoice or statement shall be presumed correct unless he or it shall notify seller in writing of such failure of delivery, shortage, discrepan cy, or error within thirty (30) days of his or its receipt of such invoice or statement, which shall be presumed to have bee n received on or before the fifteenth (15th ) day of the month succeeding purchases. 4. Seller disclaims all warranties, express or implied, to the extent permitted. 5. Purchaser agrees to immediately examine shipment and agrees to n otify seller promptly of any errors in s hipment and of any defective material supplied. 6. 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. 7. 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 UNDERSTA ND THE TERMS AND CONDITIONS THEREOF. Signature Signature