Johnson Brothers-Maverick of Arizona Credit Application

Credit Application

4250 E Superior Ave, #200, Phoenix, AZ 85040 | 620-735-8780 | info@maverickbevaz.com
This form is filed in our confidential credit file and used only in establishing credit with our company.
CUSTOMER INFORMATION
Licensed As*
Legal Entity Type*
DBA Name*
Phone #*
Address*
Store
City*
State*
Zip*
County*
Mailing Address (if different)
Preferred Payment Method: (Terms: Payment on Delivery COD)*

CheckFintech
CONTACT INFORMATION
AP Name*
Email*
example@example.com
Phone*
Buyer Name*
Email*
example@example.com
Phone*
Owner/Manager Name
Email
example@example.com
Phone
LICENSE & TAX INFORMATION
License #*
Hemp License
Category*
Fein #*
State Tax Resale #*
Banner/Concept
Chain
DELIVERY INFORMATION
Preferred Delivery Day
Earliest Delivery Time
Latest Delivery Time
Do Not Delivery Between
Continuous 4-hour time window required
Driver Instructions
ADDITIONAL INFORMATION
Sales Consultant (if known)
Additional Consultants
Customer agrees that delinquent balances on invoices over 60 days old will carry interest at a rate of 1.5% per month, and further agrees to pay all costs of collection, including reasonable Attorney’s fees. There is an additional charge for returned payments at the maximum allowed by state law.

Customer expressly agrees that the forum for any litigation pursuant to this agreement or any other contract between Seller and Customer, whether Seller or Customer brings suit, shall be the state or federal courts located in Maricopa County, Arizona, and the Customer consents and submits to the venue and jurisdiction of said courts. This agreement shall be governed by and construed in accordance with the laws of Arizona.

Customer shall make a careful inspection at time of delivery. Failure to give written notice within ten (10) days of delivery shall constitute an unqualified acceptance of the merchandise delivered and a waiver of all claims. No returned product will be accepted without prior approval. Restocking fee of 25% will be applied.

This signature gives permission to Johnson Brothers of Arizona Inc, or their agent, to verify any or all information listed on this form.
Signature*

Clear
Print Name*
Title*
Date*

MonthDayYear
Date

Your Name (as shown on page 1)*
Arizona Transaction Privilege Tax License Number*
Continued from previous page:

11. Electricity, natural gas or liquefied petroleum gas sold to a qualified manufacturing or smelting business. A manufacturing or12. Electricity or natural gas to a business that operates an international operations center in this state and that is certified by the Arizona Commerce Authority. NOTE: Certification must be attached. (Utilities classification only.) (Not available for all Cities.)13. Computer data center equipment sold to the owner, operator or qualified colocation tenant of a computer data center that is certified by the Arizona Commerce Authority pursuant to A.R.S. § 41-1519. NOTE: Equipment must qualify and certificationmust be attached.14. Sale or lease of tangible personal property to affiliated Native Americans if the order is placed from and delivered to the reservation. NOTE: The vendor shall retain adequate documentation to substantiate the transaction.15. Foreign diplomat. NOTE: Limited to authorization on the U.S. Department of State Diplomatic Tax Exemption Card. The vendor shall retain a copy of the U.S. Department of State Diplomatic Tax Exemption Card and any other documentation issued by the U.S. Department of State. Motor vehicle purchases or leases must be pre-authorized by the Office of Foreign Missions (“OFM”)See “Vehicle Tax Exemption” at www.state.gov/ofm/tax/
16.*Other Deduction: Cite the Arizona Revised Statutes authority for the deduction. A.R.S. § Description:
17.*Other Cities Deduction: Cite the Model City Tax Code authority for the deduction. M.C.T.C. § Description:
*Refer to TPT Deduction Codes for a complete list of state and city exemptions (deductions) and the business classes (codes) under which the deductions apply.
E. Describe the tangible personal property or service purchased or leased and its use below.(Use additional pages if needed.)
F. Certification

A vendor that has reason to believe that this Certificate is not accurate or complete will not be relieved of the burden of proving entitlement to the exemption. A vendor that accepts a Certificate in good faith will be relieved of the burden of proof and the purchaser may be required to establish the accuracy of the claimed exemption. If the purchaser cannot establish the accuracy and completeness of the information provided in the Certificate, the purchaser is liable for an amount equal to the transaction privilege tax, penalty and interest which the vendor would have been required to pay if the vendor had not accepted the Certificate. Misuse of this Certificate will subject the purchaser to payment of the A.R.S. § 42-5009 amount equal to any tax, penalty or interest. Willful misuse of this Certificate will subject the purchaser to criminal penalties of a felony pursuant to A.R.S. § 42-1127(B).
I, hereby certify that these transactions are exempt from Arizona transaction privilege tax and that the information on this Certificate is true, accurate and complete. Further, if purchasing or leasing as an agent or officer, I certify that I am authorized to execute this Certificate on behalf of the purchaser named above.
Print Name*
Signature*

Clear
DATE*

MonthDayYear
Date
TITLE*
Should be Empty:

CUSTOMER INFORMATION

CONTACT INFORMATION

LICENSE & TAX INFORMATION

DELIVERY INFORMATION

ADDITIONAL INFORMATION

Arizona Transaction Privilege Tax Exemption Certificate

A. Purchaser’s Name and Address:

Choose one transaction type per Certificate:

Reason for Exemption: