Application for Credit Account

Thank you for taking the first step in partnership with Peerless Block and Brick Company. In order to consider extending credit to your company or your sole proprietorship, we need you to complete the fields below, read and accept all terms, and submit the Application for Credit Account.

The more accurate information you provide the quicker the process will be.

By submitting the Application, Company and/or Applicant provides express consent to confirm credit history of the Company and/or Applicant as necessary, and that further information, including but not limited to financial statements, may be required to establish a Credit Account with Peerless Block and Brick Company.

You will need to provide your Bank Contact information as well as Trade References in order to submit this application.

Company or Applicant Name *

Does your company have a Federal Identification Number (FEIN)? *

Company Federal ID Number

Social Security Number

Business Registration State

Year Founded

Credit Amount Requested *

Tax Status *

Please Attach WV Sales Tax Certificate of Exemption

Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code

Is the physical address different from the mailing address? *

Physical Address

Street Address

Street Address Line 2

City State

Zip Code

Company and/or Applicant Phone Number *

Area Code Phone Number

Company and/or Applicant Fax Number

Area Code Phone Number

Accounts Payable Contact *

First Name Last Name

Accounts Payable Phone Number *

Area Code Phone Number

Accounts Payable Email Address (for Invoices and Statements of Account)

Please be aware that your Application for Credit Account will be processed more quickly if you alert your references that Peerless Block and Brick Company will be contacting them for information.

Bank Name *

Bank Contact *

First Name Last Name

Bank Contact Phone Number *

Area Code Phone Number

Name of Authorized Bank Account Signatory *

First Name Last Name

How many Trade References do you have? *

Trade Reference 1: Company Name

Trade Reference 1: Contact Name

First Name Last Name

Trade Reference 1: Contact Phone Number

Area Code Phone Number

Trade Reference 1: Contact Email Address

Trade Reference 2: Company Name

Trade Reference 2: Contact Name

First Name Last Name

Trade Reference 2: Contact Phone Number

Area Code Phone Number

Trade Reference 2: Contact Email Address

Trade Reference 3: Company Name

Trade Reference 3: Contact Name

First Name Last Name

Trade Reference 3: Contact Phone Number

Area Code Phone Number

Trade Reference 3: Contact Email Address

Terms of Sale

By submitting this Application for Credit Account, Company and/or Applicant understands and accepts that all payments are due withing 30 days of purchase. Furthermore, Company and/or Applicant understands, accepts and expressly agress to pay finance charges at 18% per annum (1.5% per month) for invoice balances that are over 30 days past due. For value received and in consideration of the extension of credit to the applicant by P.H.G., Inc. dba Peerless Block and Brick Company, the Company and/or Applicant hereby fullly and unconditionally guarantees payment of all materials and/or services purchased by the Company and/or Applicant under and pursuant to the terms of the Application for Credit Account. By confirming the desire to obtain credit by submitting this application, Company and/ or Applicant expressly agrees to pay all finance charges that may accrue on the account together with attorney's fees and collection expenses should they be incurred.

Company and/or Applicant Agrees to Terms of Sale *

Payment Charges Acceptance

For value received and in consideration of the extension of credit to Company and/or Applicant by P.H.G., Inc. dba Peerless Block and Brick Company, by selecting "Yes" below Company and/or Applicant fully and unconditionally guarantees payment of all materials and/or services purchased by Company, Company Representative(s) and/or Applicant under and pursuant to the Terms of Sale of the Application for Credit Account above. Company and/or Applicant further expressly agree and consents to pay all finance charges that may accrue on the account together with applicable attorney fees and collection expenses, should they be incurred. Notice of non-performance or demand is expressly waived. Failure to pay invoices within the expressly agreed upon Terms of Sale may result in Credit Account denial, refusal of future sale and/or legal action.

Company and/or Applicant has read, understands and accepts the payment charges: *

Name of Person Completing this Application *

First Name Last Name

Title of Person Completing this Application *

Phone Number of Person Completing this Application *

Area Code Phone Number

E-mail of Person Completing this Application

You must accept and acknowledge the following statement: *

I certify the information herein is true and correct and agree that I have authority to bind Company and/or Applicant to all Terms and Conditions set forth in this Application for Credit Account as well as authority to request Bank and Trade references.

Enter the message as it's shown *

REMINDER: This Application for Credit Account will be processed more quickly if you alert your references that Peerless Block and Brick Company will be contacting them for information.