Prosource Account Application

Prosource Account Application
Date*

MonthDayYear
Date
Sales Rep your are working with:
Company*
Contact Name*
First and Last Name
Position/Title*
ex. Property Manager, Wellness Director, etc.
E-mail Address*
example@example.com

Billing Information
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County
Phone*
Phone Extension (if applicable)
Fax

Physical Location Information

Same as Billing
DBA Company (If different than above)
Contact Name
Title
Email
example@example.com
Physical Address

Street Address Line 2

CityState

Zip Code
County
Phone
Phone Extension (if applicable)
Fax

Company Information
Account Interest (please check all that apply)

EquipmentServiceOther
Type of business or service
Number of years in business
Dun & Bradstreet Rating (if applicable)
State Exemption Certificate(s).
Tax Exempt?

YesNo1 %
If yes, attach copy of exemption certificate.

Cancelof
Is the account to be administered by a purchase order system?*

YesNo

Current Trade References

2 required
Reference 1
Name
Contact
Account Number
Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reference 2
Name
Contact
Account Number
Phone
Address

Street Address

Street Address Line 2

CityState

Zip Code

Bank Information - Main

(required)
Bank/Credit Union Name
City/State
TERMS: Prosource Fitness Equipmentaccount terms are NET 15. All accounts due and payable according to terms stated on the invoice. A service charge of 1-1/2% per month will be charged on all outstanding balances over 60 days from the date of the invoice. This is an annual interest rate of 18%. All accounts over 60 days are automatically placed on C.O.D. until they are made current. All costs incurred for collection, including reasonable attorney fees, will be the responsibility of the applicant. I acknowledge that I have read and understand the terms that are outlined above,and hereby certify that the applicant unconditionally agrees to abide by them. I am authorized to sign this request for credit.
Signature
Signature

Clear
Type your full name as it appears in your signature.
Your Title
Date

MonthDayYear
Date
Should be Empty: