SSC CREDIT APPLICATION & AGREEMENT

CREDIT APPLICATION & AGREEMENT
SSC‐Customer Credit Application
Date*

MonthDayYear
Date
Account Number*
Total Amount Requested*
One TimeRevolving
Purpose of Credit*
Collateral Info.
APPLICANT'S INFORMATION
Last Name:*
First Name:*
Social Security Number:*
Date of Birth:*

MonthDayYear
Date
PalauanForeigner
ID Number:*
ID Type: *
Issue Date:*

MonthDayYear
Date
Expiration Date:*

MonthDayYear
Date
Current Home Address:*
Years at Residence:*
Permanent Mailing Address:*
E‐mail Address:*
example@example.com
Home Phone Number:
Please enter a valid phone number.Format: +000-000-0000.
Mobile Phone Number:
Please enter a valid phone number.Format: +000-000-0000.
Work Phone Number:
Please enter a valid phone number.Format: +000-000-0000.
EmployedSelf-employedRetireeOther
Current Salary/Income per month:*
Other Income per month:
Name of Business (if ‐self‐employed):
Current Employer:*
Years with Current Employer:*
Position:*
Supervisor's Name:*
Supervisor's Contact Number*
Please enter a valid phone number.Format: +000-000-0000.
Credit History*
Under credit information below, list every person and or/business to whom you owe money and the amount owed. Also list every court case in which you have been sued for debt.
CREDIT INFORMATION

Rows	Name of Bank	Current Balance	Monthly Payment	Date of Last Payment

Rows	Name of Bank	Current Balance	Monthly Payment	Date of Last Payment

Rows	Name of Bank	Current Balance	Monthly Payment	Date of Last Payment

Rows	Name of Creditor	Current Balance	Monthly Payment	Date of Last Payment

Personal Reference
Name*

First NameLast Name
Relationship*
Contact Number*
Please enter a valid phone number.Format: +000-000-0000.
GUARANTOR'S INFORMATION
Name*

Last NameFirst Name
Relationship to Applicant*
Social Security Number *
Date of Birth*

MonthDayYear
Date
PalauanForeigner
ID Number*
ID Type*
Issue Date*

MonthDayYear
Date
Expiration Date*

MonthDayYear
Date
Current Home Address*
Years at Residence*
E‐mail Address*
example@example.com
Permanent Mailing Address:*
Home Phone Number
Please enter a valid phone number.Format: +000-000-0000.
Mobile Number
Format: +000-000-0000.
Work Phone Number
Please enter a valid phone number.Format: +000-000-0000.
EmployedSelf‐employedRetireeOther
Current Salary/Income per month:*
Other Income per month*
Name of Business (if ‐self‐employed):
Current Employer*
Years with Current Employer*
Position*
Supervisor's Name*
Supervisor's Contact Number*
Credit History*
TERMS & CONDITIONS
Information presented in this application and in all documents submitted in connection herewith is for the purpose of obtaining credit and is represented to be true and complete. The applicant authorizes Surangel & Sons Co. to investigate all credit references and any other matter pertaining to this request for credit. The undersigned authorizes its banks, trade creditors and the guarantor(s) to submit complete information for the purpose of credit evaluation.
The parties hereby agree that in the event of litigation arising from this transaction, venue shall be the Republic of Palau. Immediate payment shall be rendered or at date and terms mutually agreed upon by both parties in writing below under "AGREEMENT FOR CREDIT ACCOUNT". Any amount unpaid after 30‐days from invoice date shall bear 1.5% interest charge per month. Applicant and guarantor(s) shall be responsible for all legal costs, collection agency expenses, and reasonable attorney’s fees incurred in any manner in connection with collection of any account past due detailed in "AGREEMENT FOR CREDIT ACCOUNT" below.

The Applicant together with the Guarantor(s) are jointly and severely responsible for this credit.
Applicant (Debtor):*
First & Last Name
Guarantor (Debtor):*
First & Last Name
AGREEMENT FOR CREDIT ACCOUNT
This agreement is made and entered into on this Day* day of Month* , Year* by and between Applicant named above and guarantor named above (hereinafter referred to as "Debtors") and Surangel S. Whipps Sr., dba Surangel & Sons (hereinafter referred to as "Creditor").
1. Debtor's owe to Creditor and promises to pay (in lawful money of the United States) to Creditor at Creditor's office in Koror, Palau, the amount of $ Dollar Amount* (the "principal") from Month and Day* , Year* until paid in full. Such amount will be paid according to the following schedule:
  1. Equal monthly payments of $ Dollar Amount* beginning on Month and Day* , Year* and continuing to be paid every month thereafter until the total balance is paid as stated next; and
  2. Final payments of remaining balance on or by Month and Day* , Year* :
  3. Debtors hereby waive notice and demand for payments.
2. Debtors may prepay all or any part of the principal amount at anytime.
3. If Debtors default in the payment of principal, interest, or other fees or charges when due hereunder and the default is not cured within ten (10) days after demand by the Creditor, then the Creditor has the option to accelerate and declare the unpaid principal sum hereunder together with all charges and interest accrued thereon to be immediately due and payable, and such principal sum, charges and interest shall thereupon become and be due and payable without presentment, demand, protest or notice of any kind, all of which are hereby expressly waived. Failure to exercise this option shall not constitute a waiver of the right to exercise the same in the event of the same or any subsequent default.
4. All types of credits, unless exempted by the Creditor, which are unpaid after 30 days from invoice date are subject to interest charge at the rate of 18% a year or 1.5% every month of the unpaid principal balance. Also, if Debtors default in the payment according to the schedule mentioned above and payment is not made 15 days after due date, then Debtors shall be liable for a late charge equal to 5% of such payment. In light of the great difficulty in determining Creditor’s damages and expenses of collecting the unpaid payments, Debtors agree that this is a reasonable late charge.
5. If Debtors fail to make timely payments, including the late charge and interest, and Creditor needs to use or hire an attorney and/or file suit to collect such amounts or to enforce this Contract, then, as further consideration for Creditor extending this credit and making this Contract, Debtors shall be liable for and shall pay all of Creditor's reasonable collection expenses, court costs, and attorney fees incurred before filing any lawsuit or claim, in the trial court, in any post‐judgment proceedings, and in any appeal, until the amounts due hereunder are paid in full, and Debtors WAIVE the protections and provisions of RPPL 7‐11 (14 PNC §2110(a) as to Debtor’s right to claim property as exempt from execution or judicial process or seizure or sale and §2111 as to limits on legal fees and expenses claimed by Creditor). The preceding sentence does not merge into a judgment. Payments are applied first to interest, late fees, attorney fees, costs, and then to the principal.
Applicant (Debtor):*
First & Last Name
Guarantor (Debtor):*
First & Last Name
Authorized Purchasers:
First & Last Name
First & Last Name
First & Last Name
First & Last Name
Upload Quotation

(If Applying for Specific Item/s)
Cancelof
Copy of Latest Check Stub/Retirement Verification/Tax Returns (Applicant)*

Cancelof
Copy of Latest Check Stub/Retirement Verification/Tax Returns (Guarantor)*

Cancelof
Copy of Valid ID (Applicant)*

(Passport, Palauan ID, Work Permit for foreigners)
Cancelof
Copy of Valid ID (Guarantor)*

(Passport, Palauan ID, Work Permit for foreigners)
Cancelof
IMPORTANT REMINDERS:
• Incomplete applications will not be processed.
• Applications are for store credits only. We do not provide cash loan
services.
Thank you for understanding!
Should be Empty:

CREDIT APPLICATION & AGREEMENT

APPLICANT'S INFORMATION

CREDIT INFORMATION

Personal Reference

GUARANTOR'S INFORMATION

TERMS & CONDITIONS

AGREEMENT FOR CREDIT ACCOUNT

Authorized Purchasers: