Company Name & Location
Billing Address (if different)
Company Address
Company Ownership Information
Type of Business State Incorporated Date Bus. Started Nature of Business
Principal or Officer Title S.S.#
Banking & Finance Reference
Bank Name Address
Account Numbers
Checking Savings Dun & Bradstreet#
Trade References
Company Name Contact Phone #
I Agree that, if I default on this agreement this company will forward my account to a collection agency for collections. I also understand I will be required to pay any and all collection expenses including but not limited to return check charges, collections fees, court costs, attorney fess and highest interest allowed by law per annum in addition to the amount owed together with such damages as are permitted and prescribed by law.
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