AccuLab Optical Credit Application

AccuLab Optical Credit Application

800-688-3904 · www.acculab.net · info@acculab.net
Company Information

* Red asterisk indicates required field
Company Name*
DBA Name
Primary Contact Name*
Primary Contact Phone Number*
Format: (000) 000-0000.
Primary Contact E-mail*
example@example.com
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Phone Number*
Format: (000) 000-0000.
How Long?
Landlord
Landlord Phone
Please enter a valid phone number.Format: (000) 000-0000.
Estimated Annual Sales*
Sales Area
IncorporatedPartnershipDBA

Business and Credit Info
Owners, Principals, and Officers
Owners, Principals, and Officers (1)*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
- Owners, Principals, and Officers (2)
  
  First NameLast Name
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.

Bank References
Bank Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Banker Name
SavingsCheckingLoan
Credit Terms are 30 days from date of invoice. Outstanding balances are subject to 1.5% per month interest. The undersigned authorizes and releases all banks, persons and companies listed on this application to furnish information and authorizes the checking of credit. The undersigned agrees to pay all collection costs, court costs, and legal fees incurred to collect delinquent balances
Name*
Title*
Date*

MonthDayYear
Date
- Name
- Title
- Date
  
  MonthDayYear
  Date

Credit CardACH
AUTOMATED SCHEDULED CREDIT CARD PAYMENT AUTHORIZATION

Schedule your payment to be automatically charged to your Visa, MasterCard, American Express or Discover Card. If you prefer ACH Payment, you can enter '0' in the required fields and go to the next page.
Recurring Payments Will Make Your Life Easier:
· It’s convenient (saving you time and postage)
· Your payment is always on time (even if you’re out of town), eliminating late charges

Here’s How Recurring Payments Work:
You authorize regularly scheduled charges to your credit card. You will be charged the amount indicated below each billing period. A receipt for each payment will be mailed to you and the charge will appear on your bank statement. You agree that no prior-notification will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.
I (full name)* authorize AccuLab to charge my credit card indicated below for full amount on the 10th of each month for payment of my Lab statement.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Acculab in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of an ACH Transaction being rejected for Non Sufficient Funds (NSF) I understand that Acculab may at its discretion attempt to process the charge again within 30 days, and agree to an additional charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank or credit card company; so long as the transactions correspond to the terms indicated in this authorization form.
Signature

Clear
Date

MonthDayYear
Please choose today's date

AUTOMATED SCHEDULED DIRECT PAYMENT VIA ACH (ACH DEBIT) AUTHORIZATION

Direct Payment via ACH is the transfer of funds from an account for the purpose of making a payment. If you chose Credit Card Payment, please complete the previous page, enter '0' in the required fields on this page, and continue.
I (we) authorize AccuLab of Illinois to electronically debit my (our) account (and, if necessary, electronically credit my (our) account to correct errouneous debits) as follows:
Checking AccountSavings AccountPrefer Credit Card
at the depository financial institution named below (“DEPOSITORY”). I (we) agree that ACH transactions I (we) authorize comply with all applicable law.
Bank Name*
Name on Account*
I (we) understand that this authorization will remain in full force and effect until I (we) notify COMPANY in writing that I (we) wish to revoke this authorization. I (we) understand that COMPANY requires at least 30 days prior notice in order to cancel this authorization.
Name(s)
Separate multiple names with commas
Signature

Clear
Date

MonthDayYear
Date

Trade References
Reference 1: Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Contact
- Reference 2: Name
- Address 2
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Phone Number 2
  Format: (000) 000-0000.
- Contact

Please, choose the email address(es) where you would like to receive the following reports:

Please Complete Each Section (Type "NA" if using the same as 'Shipping Email')
Shipping Email*
example@example.com
WIP Reports Email*
Delay Notices Email*
Credit Notices Email*
Statements Email*
Payment Email*

Personal Guarantee

In consideration for credit extended, the undersigned contracts and guarantees to the faithful payment, when due, of all accounts of the company seeking credit for 5 years from the date of this application. The undersigned guarantor expressly waives all notice of acceptance of this guarantee, notice of extension of credit, presentment of demand for payment and any notice of default by the company seeking credit and all other notices the guarantor might be entitled to. Revocation of the guarantee shall be in writing and delivered by certified mail.
Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
Please verify that you are human*
- Signature
  
  Clear
- Date
  
  MonthDayYear
  Date
- Print Name
- Should be Empty:

AccuLab Optical Credit Application

Company Information

Business and Credit Info

Owners, Principals, and Officers

Bank References

AUTOMATED SCHEDULED CREDIT CARD PAYMENT AUTHORIZATION

AUTOMATED SCHEDULED DIRECT PAYMENT VIA ACH (ACH DEBIT) AUTHORIZATION

Trade References

Please, choose the email address(es) where you would like to receive the following reports:

Account Setup Details

Personal Guarantee