Business Name
Branch -
Division
- Subsidary
- Of
Billing Address
City
State/Province
Zip/Postal Code
Country
Email
Telephone
Fax
*
*
Type of Business
How long in business?
Corporation
- Partnership
- Proprietorship
- LLP
- LLC
Owners/Officers
1.
Title
Ph.
2.
Title
Ph.
3.
Title
Ph.
Bank Reference
Bank Name
Account #
Contact
Ph.
Trade References
1.
Ph.
Fax
2.
Ph.
Fax
3.
Ph.
Fax
4.
Ph.
Fax
Taxable?
Yes or
No -
If no, state certificate required for county and /or state in which delivery occurs:
THE STATEMENTS MADE ON THIS CREDIT APPLICATION, FOR THE PURPOSE OF OBTAINING CREDIT, ARE TRUE AND CORRECT AND THE SIGNER AUTHORIZES MASKELL-ROBBINS TO OBTAIN CREDIT INFORMATION FROM OTHER BUSINESSES, INCLUDING BANKS. WE ALSO UNDERSTAND THAT MASKELL-ROBBINS WILL ADD A SERVICE CHARGE OF 1.5% PER MONTH, 18% PER ANNUM TO ALL PAST DUE INVOICES, EXCEPT WHERE PROHIBITED BY LAW. WE UNDERSTAND THAT AN INVOICE IS CONSIDERED PAST DUE IF NOT PAID WITHIN 30 DAYS OF INVOICE DATE AND SERVICE CHARGES ARE ASSESSED MONTHLY ON ALL PAST DUE INVOICES. WE DO HEREBY AGREE TO PAY THE SAME. THE UNDERSIGNED FURTHER AGREES TO PAY ALL EXPENSES INCLUDING COURT COSTS, LEGAL AND ADMINISTRATIVE EXPENSES, AND ATTORNEY FEES PAID OR INCURRED BY MASKELL-ROBBINS IN ENDEAVORING TO COLLECT SUMS DUE AND OWING BY THE COMPANY.
Applicant Name
Applicant Title
Date