SSI Business Credit Application Form

Name of Company *

Contact Name*

PrefixFirst NameLast Name

Title/Position

Phone Number

Area CodePhone Number

Email Opt-In (where invoices & updates can be sent)*

example@example.com

Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of Safety Services, Inc. Account Manager Working With You

Industry Type

Tax I.D. Number

In Business Since :

Date

Business Structure*

Tax Status*

If Tax Exempt, please upload your tax exemption certificate here or provide it to your Account Manager.

Browse Files

Number of Employees

Ship-To Address (where you can receive product)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Institution Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What type of account would you like to establish with Safety Services*

Credit Card/Cash OnlyTerms Account

Amount of Credit Requested

If unknown, enter 0.

DUNS Number

If applicable

Are you interested in paying via ACH/EFT?

YESNO

Don't know your DUNS Number...click this link to look up your DUNS Number.

Have you or your officers or affiliates ever filed a petition in bankruptcy?*

YesNo

If so, describe

Is your company subject to any litigation?*

YesNo

If so, describe

Terms & Conditions

TERMS AND CONDITIONS

1. CORRECTNESS OF INFORMATION.
By submitting this form, you affirm that the information provided herein are true and correct. Any misrepresentation or incorrect information found maybe cause for denial or rejection of credit.

2. DISPUTES IN CASE OF BREACH.
In case of dispute, claim, or controversy arising due to breach of this agreement, the parties may submit to arbitration chosen by both parties. The parties shall divide the cost and expenses to the proceeding in equal shares. Further, the losing party shall pay the cost of attorney's fees of the prevailing party, other than the dispute award.

3. CONFIDENTIALITY.
Any information acquired through the course of this agreement shall be recognized as Confidential Information. The parties shall keep confidential the confidential information and shall exercise the same degree of care required by law.

4. SEPARABILITY CLAUSE.
Should any provision of this Agreement be held invalid by any competent court, the same shall apply only to the provision involved and the remaining provisions hereto shall remain valid and enforceable.

5. AGREEMENT MODIFICATION.
Any modifications or alterations to this agreement shall only be considered as agreed by the parties in the existence of a written document signed by both parties.

6. COUNTERPARTS.
This agreement may be executed in two or more counterparts each of which shall be deemed an original and all of which together shall constitute one and the same agreement.

7. GOVERNING LAW.
This agreement shall be governed by and construed in accordance with and only of the laws of the State of Michigan.

8. RELATIVITY.
This agreement inures to the benefit of, and is binding upon the successions and assigns of the parties hereto.

9. NON-WAIVER.
The failure of any party to insist upon the strict compliance with and performance of any of the terms, conditions, and covenants shall not be deemed as a waiver of said party may have over such breach. Only by expressed written consent and duly signed by the parties may a proper waiver be considered as having been made.

Signature*

SAFETY SERVICES, INC. | 800.632.2988 | safetyservicesinc.com

Corporate Office: 5286 Wynn Road, Kalamazoo, MI 49048

Phone: 269.382.1052 | Fax: 269.382.6414

Satellite Service Center: 5510 33rd Street SE, Grand Rapids, MI 49512

Phone: 616.956.6060 | Fax: 616.956.7708

Business Credit Application Form

Authorized Employee Information

Company Information

Banking Information

Financial Information