HEIN ELECTRIC SUPPLY COMPANY CREDIT APPLICATION

HEIN ELECTRIC SUPPLY COMPANY
APPLICATION FOR OPEN ACCOUNT
Address:

2030 S. 116 Street

PO Box 270225

West Allis, WI 53227

Phone (262) 790-8400 | Fax (262) 790-5555

This application is covered by the Equal Credit Opportunity Act, its amendments and Regulation B. Business credit will not be denied because of age, marital status, sex, race, religion or national origin.
GENERAL INFORMATION:
Legal Business Name*
Address*

Billing Address

Street Address Line 2

CityState

Zip
Address

Shipping Address

Street Address Line 2

CityState

Zip
Business Telephone ( )*
Fax Number ( )
Email address if you would like invoices/statements emailed
example@example.com
Accounts Payable Contact
Check One:

Corporation / Include Federal Tax ID Number (below)Individual / Social Security Number (below)Partnership / Include Social Security or ID Number (below)
If you selected Corporation or Partnership, Input Your Federal Tax ID Number
If you selected Individual, Input Your Social Security Number
Date Business Established

MonthDayYear
Date
Type of Business
Is PO Required:

NoYes
PRINCIPALS / OFFICERS:
Owner

First NameLast Name
President

First NameLast Name
Home Address

NoIf yes, answer the following questions
Home Address
Home Phone
Business Name
Were any principals in business before?

YesNo
BANK / TRADE REFERENCES:
Bank Name
Address
Contact
Acct No’s.
Telephone
*****We must have email addresses for all trade references. We cannot process this application without them.******
Supplier Name
Telephone
Email
example@example.com
Address City, State, Zip
Supplier Name
Telephone
Email
example@example.com
Address City, State, Zip
Supplier Name
Telephone
Email
example@example.com
Address City, State, Zip
This application must be completed in full and signed before processing.
EXEMPTIONS:
Are you Sales Tax Exempt:

YesNo
If you are exempt from Wisconsin sales tax, please include a tax exemption certificate, completed and signed, with this application.
FINANCIAL INFORMATION:
Complete information below, or attach copy of most recent financial statement.
Cash on Hand & In Bank
ASSETS
Accounts / Notes Receivable
ASSETS
Inventory (Present Cost)
ASSETS
Net Fixed Assets
ASSETS
All Other Assets
ASSETS
TOTAL ASSETS
ASSETS
Accounts Payable
LIABILITIES
Notes Payable
LIABILITIES
Accrued Taxes
LIABILITIES
All Other Liabilities
LIABILITIES
TOTAL LIABILITIES
LIABILITIES
TERMS OF SALE AND PERSONAL GUARANTY:
To induce HEIN ELECTRIC SUPPLY COMPANY to extend credit for purchases under credit sales, I/We agree to pay under the terms stated on each invoice. I/We agree to pay service charges at a rate of 1-1/2% per month (18% APR) for any invoice more than 30 days past due. HEIN ELECTRIC SUPPLY COMPANY reserves the right to place accounts on hold if aging balance is 30 or more days old. Guarantor (s) further agrees to pay all expenses, including expenses of court costs, interest and attorney’s fees paid or incurred by

This Guaranty shall be enforceable before or after proceeding against Applicant(s) or simultaneously therewith, and without resort to any security. The incorporation, merger, or sale of Applicant(s), business shall not terminate this Guaranty, and the Guaranty shall continue as to any credit extended such other entity.

This Guaranty shall continue in force until notice in writing of termination sent by registered or certified mail, return receipt requested, is received by HEIN ELECTRIC SUPPLY COMPANY. This notice is to specify the date on which the Guaranty is to be terminated.
I/We hereby authorize you to whom this application is made or your agents to investigate my/our financial responsibility and credit worthiness and will provide financial statements, tax returns, etc., as you deem necessary.

MonthDayYear
Date
Guarantor Signature X

Clear
Date

MonthDayYear
Date
Guarantor Signature X

Clear
Authorization to Release Bank Information
This is authorization to release information to HEIN ELECTRIC SUPPLY COMPANY, for the purpose of supporting the Credit Application and establishing open credit. This information will be held in strict confidence.
Authorized Signature*

Clear
Title*
Date

MonthDayYear
Date
Account Name Per Bank Records*
Account Number/s*
This application cannot be processed without authorized signatures (above X’s Completion of this credit application can be mailed or faxed to our Credit Department. All associates of Hein Electric Supply Company thank you for allowing us to serve you.
Should be Empty:

HEIN ELECTRIC SUPPLY COMPANY

APPLICATION FOR OPEN ACCOUNT

GENERAL INFORMATION:

PRINCIPALS / OFFICERS:

BANK / TRADE REFERENCES:

EXEMPTIONS:

FINANCIAL INFORMATION:

TERMS OF SALE AND PERSONAL GUARANTY:

Authorization to Release Bank Information