VICTORY FOODSERVICE CUSTOMER ACCOUNT APPLICATION

CUSTOMER ACCOUNT APPLICATION

515 Truxton Street, Bronx, NY 10474 | (718) 378-1122
Date

MonthDayYear
Date
Sales Representative (if applicable):
Business Contact Information:
Please select one of the following options:

Sole ProprietorshipPartnershipCorporationOther
Legal Business Name:
DBA:
Business Phone Number:
Please enter a valid phone number.
Fax Number:
Please enter a valid fax number.
Email
example@example.com
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Delivery Hours
Please provide a 4-hour window of time you prefer for deliveries
Accounts Payable Contact:

Full NameLast Name
Accounts Payable Contact Telephone:
Please enter a valid phone number.
Date Business Commenced:

MonthDayYear
Date
Federal Tax ID:
Resale No.:
Owner/Shareholder Contact Information:
Owner/Shareholder Name:

First NameLast Name
Social Security Number:
Date of Birth:

MonthDayYear
Date
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid cellphone number.
Drivers License ID:
State Issued:
State Issued:
Owner/Shareholder Name:

First NameLast Name
Social Security Number:
Date of Birth:

MonthDayYear
Date
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number
Please enter a valid cellphone number.
Drivers License ID:
State Issued:
State Issued:

Credit Information Release Form

In connection with my application, I authorize all banks, corporations, companies, credit agencies, accountants to release any information that they have about me to Victory Foodservice, or its agency and I release them from any and all liability and responsibility from doing so. Further, I authorize the procurement of all investigative consumer report and understand that such а report may contain information about my background, character and personal reputation. I understand this notice will also apply to future update reports that may bе requested. I understand that any misrepresentation bу me may bе the cause of rejection.
Full Name:

First NameLast Name
Release of Bank Information (Please Sign Below):

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Social Security Number:
Date of Birth:

MonthDayYear
Date
Complete Applicant's Present Residence:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business/Trade References
Company Name:
Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Terms:
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number if applicable.
Company Name:
Company Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Terms:
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid fax number if applicable.
Agreement

1) AII invoices must bе paid according to the terms stated on your invoices. 2) AII credits for returns or shortages must bе noted on your invoice bу our driver. 3) А monthly finance charge of 1.5% will bе assessed to you on all past due accounts. 4) Notification of changed in ownership must bе sent immediately to Victory Foodservice bу registered mail, return receipt requested. 5) Your terms are not transferable to а new owner. 6) Items received but not paid for will not become the property of the new owner. 7) If this account is placed for collection or а legal proceeding, you agree that all reasonable charges and attorney's fee and disbursement equal to 33% or 1/3 of the amount due will bе added to the face amount due to constitute our claim. 8) AII returned checks are subject to а $40.00 charge and an immediate stop/lock of account. Orders cannot bе processed unless return check has been satisfied. The return of two checks will place the account on an indefinite CASH ONLУ probationary period.
Name

First NameLast Name
Signature

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Title
Date

MonthDayYear
Date
Name

First NameLast Name
Signature

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Title
Date

MonthDayYear
Date

Personal Guarantee
I, First Name Last Name , residing at Street Address Address Line 2 City State Zip , for and inconsideration of your extending credit at my request to (business name) herein after referred to as 'the business", hereby personally guarantee to Victory Foodservice the payment of any obligation of the business and hereby agree to Ьind myself to рау Victory Foodservice on demand of any sum which may become due to Victory Foodservice Ьу this business whenever the business shall fail to рау the same. lt is understood that I hereby waive notice of default, non-payment, and notice thereof and consent to any modification or renewal of the credit here by guaranteed.
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Business Name:
Guarantor:
Guarantor Signature:

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Social Security Number:
Date of Birth:

MonthDayYear
Date
Witness Name:
Witness Signature:

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Today's Date

MonthDayYear
Date

Recurring ACH Payment Authorization

You authorize regularly scheduled charges to your checking/savings account. You will be charged the amount indicated below each billing period. 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 First Name Last Name authorize Victory Foodservice Dist. Corp to charge my bank account indicated below, for the total amount of my purchases 7 days after the delivery date.
Billing Information
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Bank Details
Account Type

CheckingSavings
Account Name
Bank Name
Account Number
Routing Number
I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Victory Foodservice Dist. Corp 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 Victory Foodservice Dist. Corp. may at its discretion attempt to process the charge again within 2 days, and agree to an additional $40.00 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 bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form.
Account Holder's Signature

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Date

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Date
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CUSTOMER ACCOUNT APPLICATION

Business Contact Information:

Owner/Shareholder Contact Information:

Please Tell Us About Your Business:

General Business Information:

Bank Information / Release Form

Credit Information Release Form

Business/Trade References

Agreement

Personal Guarantee

Recurring ACH Payment Authorization

Billing Information

Bank Details