Credit Application

Resellers do not qualify for terms. Please do not complete the credit application if you are a reseller.

Business Name *

Business Street Address *

Business Address Line 2

Business City *

Business State *

Business Zip Code *

Business Phone Number *

Business Email Address *

Shipping Information

Business Name *

Attention *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Business Information

Form of Organization (Select One) *

Date Business Established *

Amount of Pending Order *

Will you Provide us with a Purchase Order? *

Yes

No

Will you be Placing Additional Orders? *

Yes

No

If Yes, Estimate of Dollar Amount

Month/Year

Are You Tax Exempt? *

Yes

No

If yes, upload your Tax Exemption Certificate

Proprietors, Partners or Officers:

Name *

Title *

Home Address *

Name

Title

Home Address

Name

Title

Home Address

Parent Company

Name

Address

Phone Number

Trade References

Trade Reference #1

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Contact Name *

Email Address *

Trade Reference #2

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Contact Name *

Email Address *

Trade Reference #3

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Contact Name *

Email Address *

Trade Reference #4

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Contact Name *

Email Address *

Trade Reference #5

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Contact Name *

Email Address *

Trade Reference #6

Name *

Address *

City *

State *

Zip Code *

Phone Number *

Fax Number *

Contact Name *

Email Address *

L.N. CURTIS & SONS TERMS OF PAYMENT ARE: NET 30 DAYS FROM DATE OF INVOICE.

The applicant agrees to be liable and responsible for all indebtedness to L.N. Curtis & sons, agrees to pay a service charge not to exceed 1-1/2% per month of 18% per annum on all delinquent amounts. The applicant also agrees to be liable and responsible for all legal fees attributable to colletion of any delinquent amount owing to L.N. Curits & sons.

Date * +

Applicant Name *

Signature *

clear

Email Address *

Title of Applicant *

Proprietorship	Partnership
Corporation	Government/Municipality
Educational	Other