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 #: __________________________