Credit Application

Credit Application
2923 5th Avenue South Birmingham, AL 35233-1503

(205) 326-3456 | (205) 325-8134 | 1(800) 832- 8200
General information

Please answer all questions in order to help us process your application as promptly as possible.
Name of Business*
D/B/A
Date*
Billing Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Anticipated Monthly Purchase Dollar Amount
Ship to Name / Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Terms Requested*

Net 30 DaysC.O.D.
Are Purchase Orders Required?*

YesNo
Tax Exempt Status*

YesNo
If Division/Subsidiary, Name of Parent Company
Tax I.D. #
How would you prefer your invoices to be delivered?*

EmailFaxMail

Contact Information
Purchasing / Buyer Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Fax
E-mail*
Payables Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Fax
E-mail*

Business Information
Type*

ProprietorshipPartnershipCorporationLLC
Partner / Owner Name*

First NameLast Name
Title*
SSN*
Name of Company Principal Responsible for Buisness Transactions*
Title*
Additional Partner / Owner Name

First NameLast Name
SSN
Additional Partner / Owner Name

First NameLast Name
SSN
Corporate Tax ID #*
Year Of Incorporation*
State Of Incorporation*
Years In Business*

Trade References
Contact*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number*
Phone Number*

Area CodePhone Number
Fax
Contact*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number*
Phone Number*

Area CodePhone Number
Fax
Contact

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number
Phone Number

Area CodePhone Number
Fax

Banking References
Contact*

First NameLast Name
Location*
Phone Number*

Area CodePhone Number
Fax
Account Type *

CheckingSavingsLoan
Account Number*
Balance $*
Account Type

CheckingSavingsLoan
Account Number
Balance $

Applicants Name (Owner, Officer, or Partner)*

First NameLast Name
Signature*

Clear
Use mouse if on desktop. Sign with stylist or finger with tablet.
Date*

MonthDayYear

Condition of Sale

A monthly charge of 1 ½% (18% per year) will be applied to all invoices over 30 days old. The purchaser agrees to pay all costs of collection including a reasonable attorney’s fee in the event invoices are placed with an attorney for collection whether a suit is brought or not. Purchaser shall pay seller a bank fee for all checks returned by the purchaser’s bank regardless of reason. Purchaser herein consents to the entry of Confession of Judgment on failure to make payment within reasonable terms as defined by Imperial Dade. To secure the full and timely payment by Purchaser to Seller of all existing and hereafter arising amounts due seller , Purchaser hereby grants to Seller a priority (purchase money) security interest and lien in and to all goods, inventory, equipment and fixtures sold to Purchaser by Seller from time to time and separate security interest in all other assets of Purchaser including, without limitation; (a) all of Purchaser’s assets now existing or owned hereafter arising or acquired accounts; (b) goods for sale, lease or other disposition which have given rise to accounts and have been returned to or repossessed ionr stopped transit by applicant; and (c) goods including, without limitation, inventory, equipment, fixtures, and vehicles. Purchaser hereby authorizes Seller to file and perfect any and all statutory lien rights and any rights under indemnity or performance bonds at any time regardless of whether payment is due to seller under seller’s payment terms with application. Purchaser hereby authorizes Seller to prepare and file any Uniform Commercial code (“UCC”) financing statements, amendments to UCC financing statements and any other filings or recordings in all jurisdictions where seller determines appropriate without Purchaser’s signature, and authorizes Seller to describe the collateral in such financing statements in any manner as seller determines appropriate. The undersigned request Imperial Dade and any of its subsidiaries (herein “Imperial”) to sell and service the customer as stated in the application on page 1 and further certify that the statements made on the this application are true, correct and complete in all material respects; and the customer authorizes Imperial to investigate all references furnished pertaining to credit, including obtaining credit reports from outside agencies.

We understand these terms and Agree to abide by them.
Signature-Corperate Officer/Partner/Owner*

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Print Name (Owner, Officer, or Partner)*

First NameLast Name
Date*

MonthDayYear
Guaranty

The undersigned personally guaranties adherence to all of the above stipulations as well as full payment of all indebtedness to the Seller now existing or hereinafter incurred including any and all service charges, collection costs and attorney fees incurred as specified above and waive any presentment, demand, protest and any other notice from Imperial regarding this guaranty of payment. This guaranty will cover all sales whether or not the terms requested are COD. The use of corporate titles shall not limit the personal liability of the signatory.
Applicants Name (Owner, Officer, or Partner)

First NameLast Name
Signature

Clear
Use mouse if on desktop. Sign with stylist or finger with tablet.
Date

MonthDayYear
Applicants Name (Owner, Officer, or Partner)

First NameLast Name
Signature

Clear
Use mouse if on desktop. Sign with stylist or finger with tablet.
Date

MonthDayYear
Notice: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning this creditor is The Federal Trade Commission, Division of Credit Practices, 6th and Pennsylvania Avenue, NW, Washington, DC 20580.
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