Please fill out the form below in order to process your application for credit verification.

GENERAL INFORMATION
Firm Name:
Billing Address:
Street Address:
City:
State:
Zip Code:
E-mail:
Telephone:		Fax:
Resale No.:
TYPE OF OWNERSHIP
Individual/Proprietorship Partnership  Corporation
Type of Business:
Years in Business:
Dunn & Bradstreet No.:
BANK INFORMATION
Bank Name:
Branch:
Address:
Telephone:
Fax:
Account No.:
Representative:
E-Mail:
CREDIT REFERENCES
1.      Name:
Address:
Telephone:
Fax:
E-mail:
2.      Name:
Address:
Telephone:
Fax:
E-mail:
3.      Name:
Address:
Telephone:
Fax:
E-mail:
TERMS OF SALE:
Applicant authorizes the creditor to make inquiry of financial and related matter for the purpose of granting credit. In order to encourage prompt payment, a delinquent charge of 18% per annum will be charged on past due accounts. Upon default of payment applicant agrees to pay collection fees, reasonable attorney fees and cost of collection that may be incurred. If suit is brought, venue may be laid in Miami, Florida U.S.   The above information is warranted to be true and I/we agree to the above terms and conditions stated and do assume personal liability for payment of said applicant's account. It is understood that the credit would not be extended to said applicant without personal guarantee.
Please use the print button in your browser to print this form to receive an original signature for completion of approval process.  You can either fax or mail this form to the address below. Sign:  Title:
Terms Net 10th prox. All prices are FOB Miami, Florida and subject to change without notice. All quotations subject to prior sale and availability. To avoid delay, please furnish as complete information as possible when ordering.