EPA & Cash Account Form

EPA & Cash Account Form
EPA & CASH/ CHECK ACCOUNT FORM
Company Name*
Address*

Mailing Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
Company Phone*
Company Fax
Email Address*
example@example.com
Following is the name and certificate data for the employee holding a valid EPA Refrigerant Certificate and/or Company Information:
Name (Last, First)*
EPA Certificate #*
EPA Certification Type*
Drivers License*
DL Expiration Date*

MonthDayYear
Date
Company Ownership Type*

CorporationPartnershipSole Proprietorship
Type of Business*
Contractor License #*
Classification of License*
Fed Tax ID*
Resale Number (Tax Resale Card Required for NonTax)
It is the cardholder's responsibility to inform Johnstone Supply upon leaving Attached is a copy of the technician's certification card and current driver's license. The above information is accurate as of Any change in the status of the above certificate holder is the responsibility of the signatory of this document.
Company Name*
Date*

MonthDayYear
Date
Authorized Signature*

Clear
Name*
Title*
PO Required

YesNo
Authorized Buyers*
I personally will guarantee the payment of any dishonored checks and all costs of collection, reasonable attorney fees and court costs that are incurred by Johnstone Supply to enforce payment of any dishonored checks. | authorize Johnstone Supply to verify the information provided and gather whatever credit history it considers necessary and appropriate, including but not limited to obtaining a credit report on the company owner, partner or guarantor. Johnstone Supply may also resubmit trade reference requests if needed. | HEREBY AUTHORIZE MY BUSINESS BANK TO RELEASE ALL INFORMATION REQUESTED BY JOHNSTONE SUPPLY. By providing my signature below, I authorize Pritchard Supply to obtain a consumer credit report to release relevant credit information. I hereby authorize all corporations, credit agencies and persons to release all information they may have about me and my accounts. This authorization shall be valid in original or copy form.
PERSONAL GUARANTEE SIGNATURE*

Clear
DATE*

MonthDayYear
Date
SSN
Attach a copy of your EPA Certificate*

Cancelof
Attach a copy of your Driver's License*

Cancelof
Are you currently in one of the branches now to buy refrigerant?

YesNo
Which branch are you currently at?

AnaheimLaguna HillsLong BeachSanta Ana
Should be Empty:

EPA & Cash Account Form

EPA & CASH/ CHECK ACCOUNT FORM