Credit Application

Application for Credit Account
Which location are you applying to?
Name:

First NameLast Name
DBA: (if applicable)
Address:

Mailing Address

Street Address (if different from mailing address)

CityState / Province

Postal / Zip Code
Previous Address: (if less than 6 months at current address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number:
Driver's License Number:
Home 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.
Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
NOTE: Invoices and statements will be sent out via e-mail
Employment:
Position:
Work Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Credit References

(Name, address and phone of 30 day trade accounts)
Credit Reference #1
Credit reference #2
Credit Reference #3
Name of Bank:
Account Number:
This Application also serves as Authorization of Payless Building Supply to verify credit references listed. This Application also serves an Authorization of Payless Building Supply to pull a Credit Report.
Type of Business:
Please choose one:
Federal ID Number:
Date Established:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name and addresses of Officers or Owners:
List of People Authorized to Sign for Purchases:
TERMS:

All accounts are due and payable on the 10th of the month following purchase. Accounts not paid by the 10th of the month are considered PAST DUE. Accounts no paid by the end of the month will be charged 1.5% service charge per month, which is an annual percentage rate of 18%. In the event of default, or if litigation is brought to enforce collection on this account, purchaser agrees to pay all legal expenses and attorneys fees incurred by the seller. This account is NOT designed to be a revolving account.
By checking this box, you acknowledge that you have read and agree with the terms.
Today's Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you require a P.O.?
Contractor's License Number:
Please verify that you are human. Type the letters and numbers that appear in the box below.
Should be Empty:

Application for Credit Account

Credit References