Randy's Hardware, Inc.

PO Box 1122
14064 Timberway
Timberville, VA 22853
Phone: (540) 896-5403

Credit Application & Agreement

General Information
Business/Individual Name:*
Billing Address:*

Street Address

Street Address Line 2

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Zip Code
Physical Address is the same as Billing Address
Physical Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number:*
E-mail:*
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Type:*

AutomotiveContractorFarmIndustrialNon-ProfitProperty ManagementResaleOther
Please Upload a Copy of the Business or Contractor License. *

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Date Business Established:*

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Authorized Employee*
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Bank Name:*
Bank Representative:*
Account #:*
Credit References

Credit Reference 1:*

Credit Reference 2:*

Credit Reference 3:

Credit Reference 4:

Your Company Information
Purchasing Contact Name:*
Payables Contact Name:*
P.O. Required?*

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Tax Exempt?*

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Please Upload Tax Exemption Form:*

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List of Names of Authorized Purchasers: (Please separate with commas)*
Agreement:
In consideration for granting of credit by Randy's Do It Best Hardware (RDIB), we (I) agree that the information provided herein is accurate and that RDIB will rely on said information in granting crediting. If this application is approved and credit is extended by RDIB, we (I) are (am) to pay according to the terms of this agreement; terms being net 15th - full balance due on or before the 15th of the month following the last day of the month in the billing period. We agree to pay inerest of 1.5% per month should our account become delinquent and to pay all cost of collection, including reasonable attorney's fees.

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