Accounts Receivables Application

Accounts Receivables Application

Please fill out this form to apply for credit terms and account setup.

Applicant Information
Full Name of Applicant*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Home Address*

Street Address

Street Address Line 2
CityStateZip Code

Company Information
Company Name*
Company Address*

Street Address

Suite/Floor
CityStateZip Code
Business Tax Identification Number (TIN), SSN, or EIN*
Type of Business (e.g., Retail, Wholesale, Manufacturing)*
Number of Years in Business*
Annual Revenue (USD)*
Business Website

Credit Terms Requested
Credit Limit Requested*
How much are you requesting
Preferred Billing Cycle*

Net 15Net 30Other

Banking Information
Bank Name*
Account Number (last 4 digits only)*
Contact Branch/Person/Phone*
Enter Branch Advisor or Branch Phone Number

Trade Reference (1)
Company Name*
Contact Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Trade Reference (2)
Company Name*
Contact Name*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Terms & Conditions
Payment Terms:

All invoices are due and payable within the terms specified (Net 30 unless otherwise agreed). Late payments are subject to a 1.5% monthly finance charge (18% annual).

Default:

Any unpaid balance beyond 60 days will be deemed in default. The applicant agrees to pay all collection fees, attorney fees, and court costs in the event of default.

Guarantee:

The undersigned personally guarantees payment of all charges and accepts full liability in the event of non-payment.

Credit Revocation:

The company reserves the right to revoke credit terms at any time, for any reason, including late or missed payments.

Rental Policies Apply:

Applicant agrees that all rentals remain subject to our Rental Policy, Terms of Service, and Damage Waiver Terms.

Acceptance of Terms:

By signing below, the applicant acknowledges understanding and acceptance of these terms and authorizes the company to verify credit and trade references.

Signature
Authorized Signatory Name*

First NameLast Name
Position/Title*
Example: CEO/Owner, Director, Manager, etc
Date*

MonthDayYear
Date
Signature*

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