CREDIT APPLICATION

COMPANY INFORMATION

Legal Business Name *

DBA/Trade Name

Federal Tax ID # *

Business Type *

☐ Corporation ☐ LLC ☐ Partnership ☐ Sole Proprietor ☐ Other: ___________

Years in Business *

No. of Employees

Annual Revenue

BILLING ADDRESS

Street Address *

City *

State *

ZIP Code *

Phone *

Fax

SHIPPING ADDRESS (if different from billing)

Street Address

City

State

ZIP Code

ACCOUNTS PAYABLE CONTACT

Contact Name *

Title

Email *

Phone *

BANK REFERENCE

Bank Name *

Account # *

Contact Name

Phone

TRADE REFERENCES (minimum 3 required)

Company Name	Contact	Phone	Email

TERMS AND CONDITIONS:

Payment terms: Net 30 days from invoice date
Finance charge of 1.5% per month (18% APR) on past due accounts
Customer agrees to pay all collection costs including attorney fees
All orders subject to credit approval
Roy I Kaufman, Inc. retains security interest in goods until paid in full

AUTHORIZATION: By signing below, I certify that the information provided is true and correct. I authorize Roy I Kaufman, Inc. to verify this information and obtain credit reports. I agree to the terms and conditions stated above.

Authorized Signature *

Date *

Print Name *

Title *