| Company Name :
__________________________________________________________________________________________ |
| Phone :
______________________________________________ FAX :
__________________________________________ |
| Email :
_________________________________________________________________________________________________ |
| Web Address : http://www.__________________________________________________________________________________ |
| Shipping Address :
_________________________________________________________________________________________ |
| Years in Business : _____ |
| Check One: |
Proprietorship ____ |
Partnership _____ |
Corporation ____ |
LLC ____ |
Other ______ |
| Corporate FED ID# / Partnership # / LLC
# : ______________________________________________________________ |
| Proprietor's SSN or EIN # :
_________________________________________________________________________________ |
| Resale # (Please attach copy of resale
certificate) :
____________________________________________________________ |
|
Owners / Principals |
| Name :
____________________________________________ Position :
_________________________________________ |
| Address :
__________________________________________________________________________________________ |
| Name :
____________________________________________ Position :
_________________________________________ |
| Address :
_______________________________________________________________________________________________ |
| Name of Person who handles Payment &
Billing : ___________________________________ Position :
_____________________ |
| Email :
______________________________________________________ Phone :
________________________________ |
|
Trade References |
| Name |
Address |
Phone |
| 1.______________________________________________________________________________________________________ |
| 2.______________________________________________________________________________________________________ |
| 3.______________________________________________________________________________________________________ |
| Bank Name : ______________________________
Address : ___________________________________________________ |
| Account # : _______________________________
Phone : ______________________________ FAX : __________________ |
|
I AUTHORIZE THE BANK
LISTED ON THIS APPLICATION TO PROVIDE INFORMATION ON MY ACCOUNT TO THE
ART OF RANDY GREEN. |
|
Authorized Signature :
______________________________________________________________________________________ |
In making this application for credit, I/We
hereby agree that all amounts are payable on or before the net due date
as shown on each invoice, and if not paid on or before said date, are
then delinquent. Delinquent accounts are subject to a late fee of
1.5% per month (18% Annually) or to collection proceedings at The Art of
Randy Greens' option.
If credit is granted, I/We agree to the above terms and the undersigned
is/are responsible for Payment of the account. If I/We fail to pay
The Art of Randy Green for purchases made by Me/Us on account when due,
I/We agree to pay all costs of collection and reasonable attorneys' fees
and costs incurred by The Art of Randy Green whether or not suit is
filed hereon. Any failure of The Art of Randy Green to avail
itself of any of the remedies herein shall not be considered a waiver of
its rights to avail itself of such remedies at a later date.
This agreement is entered into in Cross Junction, Virginia, U.S.A.
|
| Signature:
_____________________________________ Title:
___________________________Date: ________________ |
|
Please attach a copy of your business license and
brief business profile. |