Credit Card Form Temp

1. Company Information
Date
Date Format: MM slash DD slash YYYY
Full Legal Name/Business Entity
Phone #
Cell phone #
Billing Address
Street Address City State / Province / Region ZIP / Postal Code
Shipping Address
Street Address City State / Province / Region ZIP / Postal Code
No. of Employees
Year Business Established
Annual Sales
Federal Tax ID (If Incorporated)
State of Incorporation
E-Mail Address(es):
Website:
2. Owner Information
Full Name (including middle initial)
Title
Social Security #
Home Address
Street Address City State / Province / Region ZIP / Postal Code
Phone #
Cell phone #
3. Bank Reference
Bank Name
Account Number
Contact
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Email
4. Trade Credit References
Company Name
Contact
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Email
Company Name
Contact
Address
Street Address City State / Province / Region ZIP / Postal Code
Phone Number
Email
5. Additional Information
Tax Exempt?
- No
- Yes (If yes please include a copy of your Certificate of Resale)
Do you require purchase orders?
- No
- Yes
Type of business:
Anticipated yearly purchases:
Credit limit requested:
Terms and Conditions
I/We certify that all the information on this form is correct. I/we fully understand your credit terms and agree to the proper payment in consideration of extended credit. Furthermore, I/we approve of your obtaining information from the above references and a credit report on my company or if not a corporation, a report on me/us personally. If you update, renew, or extend my line of credit, you may request a new report without notice.
If the account is not paid as agreed or if the credit limit is exceeded, the business charge account will be temporarily suspended, unless other arrangements are made with Wallauer management or authorized representative. Repeated late payments may result in permanently revoking your charge privileges. Payments not received within 60 days of the invoice date will receive a finance charge of 1.33% per month. Wallauer will send an electronic statement to the email provided each month detailing account activity including any monthly finance charge, service charge or other transaction charges. A $2.00 per month Service Fee will be charged for all paper statements mailed to customers. A $35.00 fee will be charged for any returned checks. You must immediately notify Wallauer of any changes to your address, email address or company ownership. The undersigned personally and unconditionally guarantees the payment of all charges accrued to the account.
Print Name
Title
Sign Name
Date
Date Format: MM slash DD slash YYYY
Office Use Only
Data Verified by:
Date
Date Format: MM slash DD slash YYYY
Account Number
New Account Approved by:
Date
Date Format: MM slash DD slash YYYY
Credit Limit:

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