Please fill in the information, and read our terms of agreement below prior to sending it.

Your Name (required)

Your Email (required)


Your Company Name

Corporation - LLC - Other (specify)

Mailing Address (Street, Zip, State, Zip)

Federal I.D. Number

Physical Address (Street, Zip, State, Zip)

Phone Number

Owner's or Offices of The Company, Position and Years in Business. (Separate information with a comma)
Example " Paul Smith, General Manager, 2 years in Business. Please list your position over the last 5 years.

Fax Number

List Your Bank Names (up to three if necessary, include the bank's addresses, and phone numbers.

Credit References
Up to three references. (Include the company name, the contact name, the phone and fax number separated with a comma)


1-To pay the balance of my account on or before the fifteenth of the month following   the date of purchase.

2- No Finance Charge if account paid when due.

3- Your account shall be subject to a Finance Charge if the account or portion thereof is not paid by the fifteenth of the month following first statement.  The Finance Charge is a “periodic rate” of 1½% per month or an Annual Percentage Rate of 18% on balances or $1.00 Minimum on amounts under ($66.66).

4- SELLER or BUYER may at any time terminate this charge account upon written notice to either party.

5- Reasonable collection or attorney fees and court costs may be charged if this agreement is referred for collections or to an attorney or collection agency.

I/We certify that the foregoing information has been supplied truthfully, accurately and voluntarily, and therefore authorize the named creditor to investigate my/our creditworthiness, credit history and financial responsibility through any credit bureau or by any other reasonable means, including direct contact with past and present creditors.  I/We also authorize banks and other financial institutions to give information to the named creditor in connection with this transaction about my/our savings and checking accounts and loans.  If credit is extended as a result of this application, I/we agree to make payment promptly in accordance with the creditor’s terms.