Singer H&R Customer Application

Customer Application
Your Sales Representative
A. General Information
Legal name of Business
Bill to Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Bill to County
Trade Name of Business
For multiple locations, upload location list here

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Ship to Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Ship to County
Phone Number
Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Accounts Payable Contact
Accounts Payable Email (separate addresses with a semicolon)
Email address for delivery of invoices/statements (separate addresses with a semicolon)
* Invoices and statements are only sent electronically. Please provide a designated email account.

OWNER, PARTNERS OR CORPORATE OFFICERS* (Please provide alternate address where we can reach you
B. Owner(s), Partner(s), or Corporate Officer(s)

Enter Information for each below.

Rows	1	2	3
Name
Title
Address
City, State, Zip
Email
Social Security #

* By signing this credit application, I authorize the person(s) listed on this credit application to carry out security related duties for the company. Social Security number required in order to carry out security-related duties for the company.
C. Description of Business
Type of Entity
Federal ID #
Incorporation Date

MonthDayYear
Date
Incorporation State
If Subsidiary, Name of Parent Company
Sales Tax Exempt (Please upload supporting documentation below)
Supporting Documentation

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D. Banking Information
Bank Name
Bank Officer
Bank Address

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Phone
Format: (000) 000-0000.
Fax
Checking Account #
Average Monthly Balance
Loan Account #
Loan Balance
E. Trade References
- Company Name
- Account #
- Contact Name
- Address
- City
- State
- Zip
- Phone
  Format: (000) 000-0000.
- Company Name
- Account
- Contact Name
- Address
- City
- State
- Zip
- Phone
  Format: (000) 000-0000.
- Company Name
- Account
- Contact Name
- Address
- City
- State
- Zip
- Phone
  Format: (000) 000-0000.
- F. Credit Information
- Credit Line Requested
- Financial Statement Enclosed (required if credit line requested is greater than $15,000)
- Upload Financial Statement / Other Related files
  
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- Listed in Dun & Bradstreet?
- Is yes, please list Dun & Bradstreet #
- G. Type of Business
- Other
- H. Building / Facility
- Mortgage holder/Landlord (Name)
- I. Agreement Acknowledgement
- Permission is hereby granted to obtain credit information from listed credit references including my bank. All financial information submitted in support of this new account and credit application is true and complete in all respects. My account is subject to a late charge of 1.5% per month (18% annual) on all past due invoices. Furthermore, I understand that my account may be turned off if my account is past due and that any collection fees (including attorney fees) incurred by Singer MS, LLC dba Singer H&R, which the parties hereby fix at 33 1/3% of any balance due plus court costs, will be borne by my account. By signing this credit application, I certify that I am authorized to make this request on behalf of the company and it is agreed that all purchases will be paid in accordance with the terms and conditions.
- Signature of Authorized Company Representative
- Print Name
- Date of Signature
  
  MonthDayYear
  Date
- J. Guarantee - Required for new accounts to be considered for credit terms
- I assume personal and individual responsibility and liability, as well as guarantee payment of all charges due and payable to Singer MS, LLC dba Singer H&R by the company listed herein. I hereby consent and authorize the use of my consumer credit report in the credit evaluation process.
- Signature of Owner, Partner or Corporate Officer
- Print Name
- Date of Signature
  
  MonthDayYear
  Date
- Should be Empty:

Customer Application

A. General Information

B. Owner(s), Partner(s), or Corporate Officer(s)

C. Description of Business

D. Banking Information

E. Trade References

F. Credit Information

G. Type of Business

H. Building / Facility

I. Agreement Acknowledgement

J. Guarantee - Required for new accounts to be considered for credit terms