Credit Application Form

Date

Legal Business Name *

Business is a *

Sole Proprietorship Partnership Corporation

Federal ID# *

State *

Date of Inc.

Years in Business *

Owner Name *

First Name Last Name

Owner Social Security # *

Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Owner Cell Phone Number *

Area Code Phone Number

Owner Home Phone Number *

Area Code Phone Number

Business Fax Number *

Area Code Phone Number

Email *

example@example.com

Buyer Contact Info

Buyer Name

First Name Last Name

Phone Number

Area Code Phone Number

Fax Number

Area Code Phone Number

Email

example@example.com

Accounting Contact Info

Name

First Name Last Name

Phone Number

Area Code Phone Number

Fax Number

Area Code Phone Number

Email

example@example.com

Billing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Shipping Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Delivery Appointment Required *

Yes No

If Yes, With Whom?

Business Number *

Area Code Phone Number

Fax Number *

Area Code Phone Number

Would you like access to our online ordering portal at www.compidistributors.com? *

YES NO

Web Purchaser Name

First Name Last Name

Web Purchaser Email

example@example.com

Email Order Acknowledgement

Yes No

Sales Tax Exempt? (If YES you must attach a State Sales Tax Exempt Certificate & Sales Tax Exempt Form) *

YES NO

Resale Tax Number *

PO Number(s) on Invoice *

YES NO

Job Number(s) on Invoice *

YES NO

Invoice Delivery Preference *

Email Fax Mail

Invoice Email

example@example.com

Monthly Statment Required *

YES NO

Monthly Statement Delivery Preference *

Email Fax Mail

Monthly Statement Email

example@example.com

Bank Name *

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Name of Bank Officer Handling Account *

Type(Check all that apply) *

Savings Checking Loan

Phone Number *

Area Code Phone Number

Fax Number *

Area Code Phone Number

Please furnish your latest financial statement with this application so that we may properly evaluate your account. All information furnished will be confidential.

Attach financial statement below*

*

Company

Name

Address

Title

Phone

Fax

Company

Name

Address

Title

Phone

Fax

Company

Name

Address

Title

Phone

Fax

I have trade references to upload* (If you filled out the above form then just check NO, or you can upload your Trade References instead here)

Upload Trade References? *

YES NO

I give permission to release information to Compi Distributors Inc. and any other credit bureau or agency contracted by Compi Distributors Inc. for the purpose of establishing a line of credit. Any information released to Compi Distributors Inc. will be strictly confidential.

Please Type your name (E Signature) *

Clear

Credit Limit Desired (Standard terms are Net 10th following month) *

Estimated Monthy Purchase Volume *

TERMS OF SALE - Net 10th Following Month

Unpaid charges thirty days from the date of delivery shall be considered past due and a finance charge will be added. The FINANCE CHARGE is computed at a periodic rate of 1 1/2 % per month or an ANNUAL PERCENTAGE RATE of 18% applied to the previous balance less payments or returns made during the current Billing Period. In the event that COMPI DISTRIBUTORS, INC. is required to refer your account to collection, then in addition, you will be required to pay the fees from the attorney and/or collection fees incurred, for the collection of your account along with any court costs or other necessary and reasonable expenses incurred by COMPI DISTRIBUTORS, INC. in collecting your account.

In consideration of any extension of credit by COMPI DISTRIBUTORS, INC., either now or in the future, to the above named credit applicant, on the above terms, or any other terms agreed to by said credit applicant and COMPI DISTRIBUTORS, INC., the undersigned, unconditionally, personally, jointly and severally guarantee the payment of any and all sums due or which may become due as a result of any such extension of credit.

By checking the box below next to your name(s), the undersigned acknowledges that he/she/they has/have read and understood all of the above and agrees to be fully bound by its terms.

Acknowledgement Required

Name of Applicant One *

Title of Applicant One *

I Agree *

YES

Please Type your name (E Signature) *

Clear

Other Notes/Comments

Enter the message as it's shown *