Credit Application

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Main Phone *

(###)

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Main Fax

(###)

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Date *

MM

DD

YYYY

Taxable? *

Yes

No

Bank Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Release of bank information by *

First Name

Last Name

I understand that typing my name below will have the same effect as an original signature *

Yes

No

Phone *

(###)

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Phone *

(###)

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Phone *

(###)

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I agree to keep the terms within the supplier’s credit terms. Should this Account become delinquent, I agree to pay the interest of 1 ½ % per month or the legal limit on any amount, which becomes delinquent beyond 30 days and a reasonable sum of attorney’s fees and costs of collection. Standard terms subject to credit approval are net 30 days from the invoice date. All orders are subject to credit approval and delay if account is delinquent or if credit limit is exceeded. Applicant acknowledges and agrees that this application is made and delivered in the state of California and that the exclusive place of jurisdiction for any action, suit or proceeding relating to any transactions between the applicant and Custom Industries, Inc. is the state of California. In consideration of the extension of credit the applicant, the undersigned personally guarantees all existing and future indebtedness of the applicant to Custom Industries, Inc. The above information and all other given for the purpose of obtaining materials from supplier on credit is warranted to be true and correct to the applicants best information. I hereby authorize the investigation of the references listed. All information is to be held in strict confidence and used for credit granting purposes only. Authorized representative of the applicant must sign below & attest to the financial responsibility, ability and willingness to pay invoices in accordance with the terms thereon. *

Yes

No

Date *

MM

DD

YYYY

Name *

First Name

Last Name

I understand that this e-signature below will have the same effect as an original signature. *

Yes

No