BUSINESS CREDIT ACCOUNT APPLICATION
BUSINESS INFORMATION
Legal Name(s):
d/b/a (if different):
Street Address:
City:
State:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Zip Code:
Mailing Address:
City:
State:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Zip Code:
Legal Status:
Sole Proprietorship
Partnership - State of domicile:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Corporation - State of domicile:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Limited Liability Co - State of domicile:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Years in Business:
Years at Present Address:
Dun & Bradstreet No.:
Are you a price group member?
YES
NO
If Yes, names of group(s):
Projected Purchases:
$
Monthly
$
Annually
If Applicable:
Subsidiary/Division of:
Address:
City:
State:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Zip Code:
ACCOUNTS PAYABLE / BILLING INFORMATION
Name:
Title:
Billing Address:
City:
State:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Zip Code:
Phone:
Ext:
Fax:
E-Mail:
LIST TWO (2) OWNERS, PARTNERS OR CORPORATE OFFICERS
1.
Name:
Title:
Address:
City:
State:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Zip Code:
Phone:
Ext:
Fax:
E-Mail:
2.
Name:
Title:
Address:
City:
State:
- select state -
AL-Alabama
AK-Alaska
AZ-Arizona
AR-Arkansas
CA-California
CO-Colorado
CT-Connecticut
DE-Delaware
DC-District of Columbia
FL-Florida
GA-Georgia
HI-Hawaii
ID-Idaho
IL-Illinois
IN-Indiana
IO-Iowa
KS-Kansas
KY-Kentucky
LA-Louisiana
ME-Maine
MD-Maryland
MA-Massachusetts
MI-Michigan
MN-Minnesota
MS-Mississippi
MO-Missouri
MT-Montana
NE-Nebraska
NV-Nevada
NH-New Hampshire
NJ-New Jersey
NM-New Mexico
NY-New York
NC-North Carolina
ND-North Dakota
OH-Ohio
OK-Oklahoma
OR-Oregon
PA-Pennsylvania
RI-Rhode Island
SC-South Carolina
SD-South Dakota
TN-Tennessee
TX-Texas
UT-Utah
VT-Vermont
VA-Virginia
WA-Washington
WV-West Virginia
WI-Wisconsin
WY-Wyoming
Zip Code:
Phone:
Ext:
Fax:
E-Mail:
BANK REFERENCE
Name of Bank:
Contact:
Address:
Phone:
Ext:
Fax:
TRADE REFERENCES
1.
Company:
Account #:
Contact:
Address:
Phone:
Ext:
Fax:
2.
Company:
Account #:
Contact:
Address:
Phone:
Ext:
Fax:
By completing and delivering this Business Credit Account application for consideration by SmartGoods, the undersigned, whether they are individuals, partners, members or officers ("Customer") agree that they will comply with SmartGoods’ Terms & Conditions of Sale, a copy of which can be viewed by clicking on "Terms" in the upper right hand corner above and incorporated herein by this reference, and which, Customer acknowledges, may be modified by SmartGoods from time to time. Furthermore, if approved, Customer’s opening of a Business Credit Account authorizes SmartGoods to release information to others regarding SmartGoods’ account and collection history with Customer.
Please check appropriate boxes. In connection with SmartGoods’ investigation as to whether to grant the extension of business credit as contemplated by this application, and if approved, for so long as such account remains open, I (we) hereby:
Authorize the above-named trade and bank references to release to SmartGoods, LLC, information regarding my (our) account and credit experience with them.
YES
NO
Authorize SmartGoods to obtain and utilize, on a recurring basis, but subject to and consistent with the provisions of the Federal Fair Credit Reporting Act (promulgated by 15 U.S.C. @ 1681 et seq.), a consumer credit report to evaluate my/our creditworthiness as principal(s), proprietor(s) and/or guarantor(s).
YES
NO
Personally guarantee the prompt and full payment of all indebtedness incurred hereunder, including SmartGoods’ collection costs and attorney's fees and costs if necessary, and further agree(s) this guaranty shall be primary and not secondary, and that SmartGoods shall not be required to exhaust its remedies against Customer prior to enforcing its rights hereunder, hereby waiving all rights of subrogation and set-off until all sums hereunder are fully paid.
YES
NO
Name of person(s) completing application:
Title:
Date:
Name of person(s) completing application:
Title:
Date: