C.M.A. Supply Co., Inc.
| 3201 ROOSEVELT DR. INDIANAPOLIS, IN 46218 (317) 545-4446 FAX (317) 545-5631 |
3333 INDEPENDENCE DR. FORT WAYNE, IN 46808 (260) 471-9000 FAX (260) 471-4720 |
1900 WATTERSON TR. LOUISVILLE, KY 40299 (502) 499-2221 FAX (502) 499-2241 |
9984 COMMERCE PARK DR. CINCINNATI, OH 45246 (513) 942-6663 FAX (513) 942-7546 |
910 W. IRELAND RD. SOUTH BEND, IN 46614 (574) 231-9000 FAX (574) 231-9188 |
APPLICATION FOR CREDIT
Date______________
NAME OF APPLICANT: ___________________________________________ YEARS IN BUSINESS: _________
(Company or Individual)
BILLING ADDRESS: Street: _________________________________________________ P.O.
Box: __________
City: ________________________ State: _____ Zip Code:
_________ Phone No.: _________________ Fax No.:
_________________
CHECK ONE: Corporation: ________
(Date Incorporated:_________________) Partnership:
________ Proprietorship: ________ Personal: ________
TAXPAYER I.D. (E.I.N. if Company/Social Security
if Individual): ____________________________________
TAX EXEMPT? Yes _____ # __________ No _____
PURCHASE ORDER/JOB NUMBER REQUIRED? Yes _____ No
_____
OFFICERS OR PRINCIPALS Name Title
_____________________________________________________________________
_____________________________________________________________________
BANK REFERENCE: ___________________________________________________ Phone:
_________________ Fax: _________________
BONDING COMPANY: _________________________________________________ Phone:
_________________ Fax: _________________
TRADE REFERENCE: (1)
_______________________________________________ Phone: _________________
Fax: _________________
(2)
_______________________________________________ Phone: _________________
Fax: _________________
(3)
_______________________________________________ Phone: _________________
Fax: _________________
(4) _______________________________________________ Phone: _________________
Fax: _________________
(5)
_______________________________________________ Phone: _________________
Fax: _________________
TERMS OF PAYMENT: NET 30 from date of invoice
A 1.5% per month service charge may be assessed
on all unpaid balances. Applicant agrees to pay any and all collection
costs or fees, including reasonable attorneys' fees, upon delinquency in the
account in excess of 60 days and following written notification. Applicant
consents to the jurisdiction of the county court of the local office for resolution
of any disputes arising out of any transactions.
Signature:
______________________________________
Date: _______________
Printed: ______________________________________
Title of Authorized Company Representative:
_____________________________________
FOR CREDIT DEPARTMENT USE ONLY: Approved: Yes _____ No _____
Credit Limit _________________
Approved
By: _________________________________________ Date: ________________
GUARANTY
(IF LESS THAN 2 YEARS IN BUSINESS)
The undersigned hereby agrees to personally
guarantee payment of the above Applicant's account,
according to the terms of this Application for Credit, for all amounts charged.
Signature:
__________________________________ Date: _______________ Soc. Sec.
No. __________________
Printed: _____________________________
Bank Account: _________________________