Bellsimons Credit Application 2026

Credit Application and Guarantee
Full Legal Name*
DBA Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Format: (000) 000-0000.
Shipping Address (If Different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
A/P Contact*
A/P Email*
example@example.com
Purchasing Contact
Purchasing Email
example@example.com
Owner Direct Number*
Format: (000) 000-0000.
Owner Mobile Number
Format: (000) 000-0000.
*****All Pages Must Be Completed*****

BUSINESS FINANCIAL INSTITUTION REFERENCE (Please Complete All Areas):
Financial Institution with Address and City*
Name Account is Listed Under*
Non-BorrowingBorrowing
TRADE REFERENCES
(Do not include COD accounts, utility accounts or credit cards. Please provide all information as requested below for each trade reference)*

TRADE REFERENCE*

Rows	Supplier Name and Contact Name (if Applicable)	Phone Number	Email	Customer Number	Terms and Credit Granted
1

TRADE REFERENCE

Rows	Supplier Name and Contact Name (if Applicable)	Phone Number	Email	Customer Number	Terms and Credit Granted
2

TRADE REFERENCE

Rows	Supplier Name and Contact Name (if Applicable)	Phone Number	Email	Customer Number	Terms and Credit Granted
3

TERMS OF SALE
Credit accounts are due and payable Net 30th day following date of invoice unless otherwise mutually agreed upon. A service charge of 1.5% per month (18% per annum) applies to past due accounts. I acknowledge that if the business is a partnership, all indebtedness incurred is joint and several. The amount of credit granted may be changed or credit withdrawn at any time at the discretion of BellSimons Companies. The applicant agrees that BellSimons Companies may obtain personal information about the applicant from consumer reporting agencies prior to extending credit and any time after that when the 'Applicant' remains indebted to BellSimons Companies I consent that I may receive electronic documents, such as invoices and statements of account from BellSimons Companies. An NSF fee of $30 will be charged for any returned payments from the financial institution.
CERTIFICATE AND AUTHORIZATION
I certify that all the above information is true correct and complete. I am a Principal, Owner or Partner of the business and have the authority to bind the Business. I authorize that BellSimons Companies may obtain personal credit information about the applicant from consumer reporting agencies prior to extending credit. I hereby authorize my bank named above to disclose all information on my bank dealings to BellSimons Companies. I understand that the information provided will be held in strict confidence and will be relied upon by BellSimons Companies. in extending credit.
CONTINUING GUARANTEE
*****All Pages Must Be Completed

In consideration of BellSimons Companies supplying goods to the business, I/we hereby (jointly and severally) personally guarantee payment for all such goods which you may supply to the Business. I/we personally agree that you may accept notes or acceptances for the price of goods supplied or any part thereof, may compromise the liability of the Business to you, and exercise or relinquish any security as you may think proper, without lessening or adversely affecting your rights against me/us. And I/we declare and agree that this personal guarantee shall continue to be binding and shall ensure the benefit of BellSimons Companies until it receives payment in full for goods supplied to your business.
Printed Name of Owner / Principal*
Signature of Owner/Principal*
Date Of Signing*

MonthDayYear
Date
*****All Pages Must Be Completed*****
Should be Empty:

Rows	Name and Title	Date of Birth	Phone	Email Address
1
2

Credit Application and Guarantee

CONTRACTOR LICENSE INFORMATION

BUSINESS FINANCIAL INSTITUTION REFERENCE (Please Complete All Areas):

TRADE REFERENCES

TERMS OF SALE

CERTIFICATE AND AUTHORIZATION

CONTINUING GUARANTEE