PRAIRIE SUPPLY CREDIT APPLICATION

PRAIRIE SUPPLY CREDIT APPLICATION
DATE

MonthDayYear
Date
LEGAL BUSINESS NAME
DBA OR ASSUMED NAME
CREDIT REQUESTED
PHONE NUMBER
Please enter a valid phone number.
FAX NUMBER
Please enter a valid phone number.
MOBILE NUMBER
Please enter a valid phone number.
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TIME AT ADDRESS
EMAIL ADDRESS
example@example.com
FEDERAL TAX ID
TYPE OF BUISSNESS
DATE ESTABLISHED
MORTGAGE HOLDER / LANDLORD
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER
Please enter a valid phone number.
DOES STATE, COUNTY, OR CITY REQUIRE A LICENSE? IF YES, LICENSE #
TYPE OF OWNERSHIP
PRINCIPAL:
NAME
TITLE
SSN/DRIVERS LICENSE
PRINCIPAL:
NAME
TITLE
SSN/DRIVERS LICENSE
PRINCIPAL:
NAME
TITLE
BANK REFERENCES
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONTACT
NO OF EMPLOYEES
EST. Annual Sales
TRADE REFERENCES
NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
HAS THE FIRM OR ANY OF IT'S PRINCIPALS EVER FILED FOR BANKRUPTCY? IF YES EXPLAIN.
Any misrepresentation in this application will be considered evidence of fraud, since this information is the basis for the extension of credit. As an inducement to grant credit, the undersigned warrants that the information submitted is true and correct. You are authorized to investigate the credit references and principals listed. In consideration for the extension of credit, said business promises to pay for all purchases within the agreed upon ) and agrees to pay a service charge per month of 1.5 % per month (20% annual percentage rate on all past due balances. In the event of any sales to a third party the buyer further grants to the seller a security interest in buyers equipment, contract rights, inventories, receivables, and proceeds of sales as collateral to secure the buyer's performance of all obligations. The buyer further authorizes the seller to fine a financing statement without buyer's signature.

The buyer also agrees that any invoices that go unpaid for more than (100 days) are subject to pay the following fees: interest, legal, finance charges, labor, and collections.
NAME OF BUSINESS
DATE
PRINT NAME TITLE
Signature

Powered by Jotform SignClear
PRINT NAME TITLE
Signature

Powered by Jotform SignClear

PERSONAL GUARANTEE
In consideration for _________________, extending credit to the business identified below for any materials and/or services after this date at the request of applicants or its agents, the undersigned individual hereby personally guarantees unconditionally and irrevocably the prompt payment of any sums now or hereafter owed to Prairie Supply, the business identified below whether said sums are due under open account, contract, or otherwise.

It is understood and agreed that credit, if extended, is to be on a continuing basis and may exceed estimated maximum and the business credit limit required as stated in the credit agreement between _________________ and Prairie Supply, shall not be obligated to notify the undersigned of the dates or amounts of any such credit and the undersigned waives demand, notice of default and any extension of time or any other forbearance which may be extended by.

The guaranty shall not continue in force until notice in writing, sent by registered or certified mail, return receipt requested is received by. Said notice shall specify the date on which this guaranty is to be terminated, said date not to be less the seven days after such notice is received. Such termination shall in no way release the undersigned as to any sum or debt incurred prior to such termination.
PRINT NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE NUMBER
SSN
SIGNATURE OF PERSON GUARANTEEING PAYMENT

Powered by Jotform SignClear
INDIANA GENERAL SALES TAX EXEMPTION CERTIFICATE
NAME
ACCOUNT NUMBER
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
( ) BLACKET ( ) SINGLE PURCHASE ( )DESCRIPTION OF ARTICLES

[ ] SALE TO RETAILER, WHOLESALER OR MANUFACTURER FOR RESALE ONLY

[ ]SALE OF MANUFACTURING MACHINERY, TOOLS, AND EQUIPMENT TO BE USED DIRESTLY IN PRODUCTION

[ ]SALES OF NOT-FOR-PROFIT ORGANIZATIONS, CLAIMING EXEMPT TO PURCHASE PURSUANT TO BULLETIN #10

[ ]SALES TO GOVERNMENTAL UNITS

[ ]OTHER

(EXPLAIN)_________________________________________________________

I HERBY CERTIFY UNDER PENALTIES OF PERJURY, THAT THE PROPERTY THAT IS TO BE PURCHASED BY THE USE OF THIS EXEMPTION CERTIFICATE IS TO BE USED FOR AN EXEMPT PURPOSE PURSUANT TO THE STATE GROSS RETAIL SALES TAX ACT.
Signature

Powered by Jotform SignClear
TITLE
SEND TO PRAIRIE SUPPLY: 3232 BOULDER AVE, FORT WAYNE IN, 46802 BRIANR@PRAIRIEWHOLESALE.NET/BREE@PRAIRIEWHOLESALE.NET
Should be Empty:

PRAIRIE SUPPLY CREDIT APPLICATION

PRINCIPAL:

PRINCIPAL:

PRINCIPAL:

BANK REFERENCES

TRADE REFERENCES

PERSONAL GUARANTEE

INDIANA GENERAL SALES TAX EXEMPTION CERTIFICATE