Please complete, sign and return this

                                                                                                                                Form along with a Tax Exemption

                                                                                                                                Certificate via fax to 336-375-6415.

        3848 Burlington Rd

        Greensboro, NC 27405

        336-375-5871

        Toll- Free 800-451-0693

 

Company Information

 

Company Name:  ________________________________________________________

 

Address:  ______________________________            Owner:  ____________________

______________________________________            Company Composition:

Phone:  ________________________________             Individual     Partnership

Fax:  __________________________________             LLC     Corporation

# of years in business ______                                         Sales Tax Exempt   Yes    No

                                                                                        If yes, include Tax Exemption Form

Federal Tax ID:  _____________________                  Amount of Credit Requested:  ___________

Do you require Purchase Orders Issued For Each Order?    Yes     No

 

Bank Information

Bank Name:  ____________________                           Phone Number:  _____________

Address:  _______________________________________________________________

Account Number:  _____________________                 Contact Person: _____________

 

Trade References

Company Name:  __________________________         Contact Person:  _____________

Address:  _______________________________________________________________

Phone Number:  ________________________               Fax Number:  _______________

 

Company Name:  __________________________         Contact Person:  _____________

Address:  _______________________________________________________________

Phone Number:  ________________________               Fax Number:  _______________

 

Company Name:  __________________________         Contact Person:  _____________

Address:  _______________________________________________________________

Phone Number:  ________________________               Fax Number:  _______________

 

Terms and Conditions

All accounts are COD until a credit application has been completed, reviewed, and approved.

If any indebtness incurred pursuant to this request for credit is not paid in full when due,

Net 30 days, the undersigned agrees to pay all costs of collection, including a reasonable attorneys fee.

Any balance remaining unpaid shall bear interest at the lesser rate of 1.5% per month or

The maximum rate permitted by applicable law until paid in full.

 

Name of Authorized Representative:  ______________________    Title:  ____________

Signature of Authorized Representative:  _____________________ Date:  ___________