Zimmer Advertiser Profile and Credit Application

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Applicant is
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Legal Business Name of applicant

Trade Name (DBA, if any)
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Business Street Address    Street Address     Address Line 2     City     State     Zip

Billing Address (if different from above)    Street Address     Address Line 2     City     State     Zip

Business Phone Area Code     Phone Number

Business Email    Email
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Business Type

Date Business Established    Date

If Incorporated, Date of Incorporation    Date

State Incorporated

Federal ID or Social Security #
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Who is the principal Owner or President:    First Name     Last Name
Area Code     Phone Number
Email

Partner (if applicable):    First Name     Last Name        Area Code     Phone Number
Email

Authorized Check Signer:   First Name     Last Name        Area Code     Phone Number
Street Address     Address Line 2     City     State
Zip
Drivers Lic #       (must provide if paying by check)
Date of Birth    Date    (must provide if paying by check)
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Credit ApplicationI elect to apply for credit with ZRI. Media Credit References (Must list 3. If 3 Media not available, list other creditors) Applicant certifies that all information contained herein is true and correct. Applicant grants permission to ZRI to obtain independent credit reports and other information from its references and bank and authorizes the credit reference and bank reference to release information to ZRI that may be used to determine creditworthiness. Additionally applicant grants ZRI permission to release payment history when called upon as a reference for other applicant vendors. Notwithstanding to whom bills are rendered, Advertiser, Agency, and Service, jointly and severally shall remain obligated to pay to station the amount of any bills rendered by the station within the time specified and until payment in full is received by the station. Payment by Advertiser to Agency or to Service, or payment by Agency to Service, shall not constitute payment to the station. Applicant agrees to pay all bills as rendered and agrees that overdue accounts are subject to monthly service charges of 18% per annum. Applicant agrees to pay all costs of collection, including actual out-of-pocket expenses and collection fee of twenty-five percent if collected through a collection agency or attorney. The laws of the State of Missouri shall govern all contracts entered into between Applicant and station, and all disputes may be resolved within the Courts of the State of Missouri.
Reference
Contact Name
Contact Phone
Contact Email
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Credit Application Opt OutI elect to NOT apply for credit & in doing so acknowledge that I have read, understand & will perform in accordance with the terms regarding my elected cash in advance status of payment. TERMS: CIA Accounts – Advertiser will ensure payment is delivered to Zimmer Radio, Inc 3 business days prior to schedule running. In the event that payment is not received in accordance with these terms, your schedule may be bumped until payment is received. Upon receipt of payment, any bumped spots will be made up within the current month’s schedule. If spots cannot be made good within the current month, we reserve the right to make them good the following month. If payment, Change Form, or Notice of Cancellation is not received in the current month, Zimmer Radio, Inc will proceed with its collection of the remainder of your contract in accordance with the terms of your advertising Agreement.
YESNO
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Client EmailFor Billing Purposes
example@example.com
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Client Signature
Clear
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Client Printed name
First Name
Last Name
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