Company Name & Location
Name
Company
Address
City
Zip
Phone
Fax
Email
Billing Address
(if different)
Company
Address
Company Ownership Information
Type of Business
Corporation
Partnership
Sole Proprietorship
Individual
State Incorporated
Date Bus. Started
Nature of Business
Principal or Officer
Title
S.S.#
1.
2.
3.
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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