Date: [Date]
Requested Credit Terms: ☐ Net 15 ☐ Net 30 ☐ Net 45 ☐ Net 60 ☐ Other: [Terms]
Requested Credit Limit: $[Amount]
1.1 Legal Business Name: [Company name]
1.2 DBA/Trade Name (if any): [DBA]
1.3 Entity Type: ☐ LLC ☐ Corporation ☐ Partnership ☐ Sole Proprietor ☐ Other: [Type]
1.4 State/Country of Formation: [State/Country]
1.5 Tax ID (EIN/VAT): [ID]
1.6 Website: [URL]
1.7 Business Phone: [Phone]
2.1 Billing Address: [Address]
2.2 Shipping Address: [Address] ☐ Same as billing
2.3 Accounts Payable Contact: [Name, email, phone]
2.4 Purchasing Contact: [Name, email, phone]
3. Ownership and Management (Optional)
3.1 Owner/Officer Name: [Name] — Title: [Title] — % Ownership: [**]%
3.2 Owner/Officer Name: [Name] — Title: [Title] — % Ownership: [**]%
4. Bank Reference
4.1 Bank Name: [Bank]
4.2 Branch/Address (Optional): [Address]
4.3 Account Type: ☐ Checking ☐ Savings ☐ Other: [Type]
4.4 Bank Contact (Optional): [Name/phone]
5. Trade References
Provide at least [__] trade references (suppliers you have purchased from):
5.1 Reference #1:
Company: [Name]
Contact: [Name]
Phone/Email: [Contact]
Credit terms: [Net __]
Approx. monthly spend: $[__]
5.2 Reference #2:
5.3 Reference #3 (Optional):
6. Credit Terms and Conditions
6.1 Payment Obligation. Applicant agrees to pay all invoices according to approved terms.
6.2 Late Fees (Optional). Late fees: []% per month (or maximum allowed by law) on past-due balances after [] days.
6.3 Collections (Optional). Applicant agrees to pay reasonable collection costs and attorneys’ fees where permitted by law.
6.4 Disputes. Invoice disputes must be submitted in writing within [__] days of invoice date.
6.5 Credit Limit Changes. Supplier may change the credit limit based on payment history and risk review.
Applicant authorizes Supplier to verify this application and obtain credit information, including contacting trade and bank references. Applicant represents that information provided is true and complete.
8. Personal Guarantee (Optional)
☐ Not included
☐ Included. If included, the undersigned personally guarantees payment of Applicant obligations, to the extent permitted by law.
Guarantor Name: [Full name]
Address: [Address]
Phone/Email: [Contact]
Signatures
Applicant (Authorized Representative): [Name]
Title/Role: [Title]
Company: [Company Name]
Date: [Date]
Signature: ___________________________
Supplier (Optional): [Supplier Name]
Authorized Representative: [Name]
Date: [Date]
Signature: ___________________________