Company Name: __________________________________________________________________
(HEREAFTER REFERRED AS BUYER)
Company Address: _______________________________________________________________
_______________________________________________________________
Phone Number: ( ) ___________________ FAX Number: ( ) ___________________
Dun & Bradstreet Number: _________________________ D & B Rating: ______________
Dated: _______________ Seller's Permit Number: ______________________________
(Attach photocopy of permit)
The BUYER hereby represents and warrants that it is solvent and pays its obligations. The foregoing representation and warranty shall be deemed to be
repeated in each Purchase Order issued by the BUYER, whether written or oral and shall be effectively remade each time a purchase obligation is undertaken.
The undersigned personally guarantees the costs of collection, including attorney's fees, court costs, and any unpaid amount. The undersigned BUYER gives
permission for obtaining the provided reference information. BUYER certifies that the submitted seller's permit number is correct and valid. BUYER agrees to
pay a $30.00 service charge for each return check, plus a interest charge per day of the unpaid amount. The information disclosed herein is true and shall be
updated whenever changes occur. The following information must be provided, if you wish to use company check. All information submitted shall be kept
confidential. Buyer must average $500.00 a month in purchases in order to purchase at wholesale prices.
Bank Name: __________________________________________________________________
Bank Address: __________________________________________________________________
Bank Phone: ( ) _________________ Account Number: __________________________
1. Owner/Guarantor Name: ________________________________ Title: ______________
Signature: ___________________________________ Cell or Pager: __________________
Home Address: __________________________________________________________________
(No PO Box)
Home Phone: __________________________ E-Mail: ________________________________
Driver's License #: ___________________ Social Security #: ____________________
2. Owner/Guarantor Name: ________________________________ Title: ______________
Signature: ___________________________________ Cell or Pager: _________________
Home Address: __________________________________________________________________
(No PO Box)
Home Phone: __________________________ E-Mail: ________________________________
Driver's License #: ___________________ Social Security #: ____________________