"Commercial Credit Application Form" - Indiana

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Download "Commercial Credit Application Form" - Indiana

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COMMERCIAL CREDIT APPLICATION
RETURN TO:
Premier Ag Co-op, Inc.
DBA:
Premier Companies
Premier Energy
Heyob Energy
Branch _____________________________________________________
P.O. Box 1947 • Columbus, IN 47202
812-379-9501 • Fax 812-372-6801
1.
FIRM NAME _____________________________________________
Line of Credit Desired
$______________________________
Additional Trade Name ______________________________________
Line of Credit Approved
$______________________________
________________________________________________________
Business Phone (________) ______________________________
Address __________________________________________________
Taxable
Social Security No. ____________________
City _______________________ State __________ Zip ___________
Non Taxable
Employer I.D. No. ____________________
Billing Address ____________________________________________
Retail Sales Tax Exemption
City _______________________ State __________ Zip ___________
Certified _____________
(please attach sales tax exemption certificate)
Nature of Business __________________________________________________________________________________________________
Corporation
Partnership
Proprietorship
LLC
Other
Date Business Established ______________
If incorporated, State in which incorporated ______________________ Year ___________
Person to contact regarding financial matters:
Name ___________________________________ Title _____________________________
Address ________________________________________________________________________ Phone No. (______) ________________
2.
NAMES OF OWNERS, PARTNERS or OFFICERS:
a. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
b. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
c. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
3.
BANK REFERENCES: Bank Name_____________________________________________ Branch _________________________________
Address ______________________________________________________________________________________________________________
Loan Officer _________________________________________________________________ Phone __________________________________
Bank Credit Line _________________________________
Secured?
Yes
No
Personal Guaranty
Yes
No
Explain: ______________________________________________________________________________________________________________
Checking Acct. No. ___________________
Savings Acct. No. ___________________
Loan Acct. No. ______________________
4.
TRADE REFERENCES:
a. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
Secured?
Yes
No Explain: ________________________________________________________________________________
b. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
Secured?
Yes
No Explain: ________________________________________________________________________________
SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS
COMMERCIAL CREDIT APPLICATION
RETURN TO:
Premier Ag Co-op, Inc.
DBA:
Premier Companies
Premier Energy
Heyob Energy
Branch _____________________________________________________
P.O. Box 1947 • Columbus, IN 47202
812-379-9501 • Fax 812-372-6801
1.
FIRM NAME _____________________________________________
Line of Credit Desired
$______________________________
Additional Trade Name ______________________________________
Line of Credit Approved
$______________________________
________________________________________________________
Business Phone (________) ______________________________
Address __________________________________________________
Taxable
Social Security No. ____________________
City _______________________ State __________ Zip ___________
Non Taxable
Employer I.D. No. ____________________
Billing Address ____________________________________________
Retail Sales Tax Exemption
City _______________________ State __________ Zip ___________
Certified _____________
(please attach sales tax exemption certificate)
Nature of Business __________________________________________________________________________________________________
Corporation
Partnership
Proprietorship
LLC
Other
Date Business Established ______________
If incorporated, State in which incorporated ______________________ Year ___________
Person to contact regarding financial matters:
Name ___________________________________ Title _____________________________
Address ________________________________________________________________________ Phone No. (______) ________________
2.
NAMES OF OWNERS, PARTNERS or OFFICERS:
a. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
b. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
c. Name ___________________________________ Title _________________________ Social Security No. _______________________
Residence Address __________________________________________________________________________________________________
3.
BANK REFERENCES: Bank Name_____________________________________________ Branch _________________________________
Address ______________________________________________________________________________________________________________
Loan Officer _________________________________________________________________ Phone __________________________________
Bank Credit Line _________________________________
Secured?
Yes
No
Personal Guaranty
Yes
No
Explain: ______________________________________________________________________________________________________________
Checking Acct. No. ___________________
Savings Acct. No. ___________________
Loan Acct. No. ______________________
4.
TRADE REFERENCES:
a. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
Secured?
Yes
No Explain: ________________________________________________________________________________
b. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
Secured?
Yes
No Explain: ________________________________________________________________________________
SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS
c. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
Secured?
Yes
No Explain: ________________________________________________________________________________
d. Name _____________________________________________________________________ Phone __________________________________
Address ______________________________________________________________Credit Mgr. _________________________________
Annual Purchases $ ___________________
Credit $ ___________________
Balance Currently Owed $ ___________________
Secured?
Yes
No Explain: ________________________________________________________________________________
5.
The following are authorized to charge on this account on behalf of applicant: _______________________________________________________
__________________________________________________________________________________________________________________
6.
Please attach your balance sheet and profit and loss statements for the past two fiscal year-ends.
TERMS AND CONDITIONS
It is agreed the buyer will pay all invoices within stated terms and agrees to all terms contained in invoices supplied by seller as may be amended from time to
time. In the event payment is not timely made, the buyer also agrees to pay a time-price differential charge (service charge) of the lesser of 1.5% per month (18%
per annum) or the maximum lawful rate on all overdue amounts, and to pay all collection costs incurred by the seller in enforcement of the terms and conditions
of this agreement, including court costs, actual reasonable attorney’s fees and collection agency fees, within the standards of the industry, but not less than 25%
of the unpaid amount of principal and accumulated service charge all without relief from valuation and appraisement laws.
If legal action becomes necessary by either buyer or seller, the buyer agrees that this or any contemporaneous or subsequent agreement will be governed as to
validity, interpretation, construction, effect and all other respects by laws of the State of Indiana. Buyer further agrees that in the event legal action becomes
necessary by either buyer or seller, jurisdiction and preferred venue shall remain in Columbus in the state of Indiana.
Buyer further agrees that any line of credit desired or approved is not the limitation of liability, and the undersigned expressly agrees that it will be responsible for
valid charges in excess of a line of credit either desired or approved.
Having obtained all necessary authority, the undersigned authorizes seller and its agents, attorneys and employees to investigate the credit standing, financial
circumstances and responsibility of buyer and all owners, partners, and/or officers listed, and authorizes and instructs all persons having information concerning
buyer’s credit standing, financial circumstances and responsibility to release such information to seller, its agents, attorneys or employees. This includes without
limitation, authorization for seller and its agents, attorneys, and employees to request, obtain, and use for all purposes which seller deems necessary, a copy of any
credit bureau or consumer credit report for the entities/persons listed herein at any time.
The buyer further grants to seller a security interest in buyer’s equipment, contract rights, inventories, receivables and proceeds of sales as collateral to secure the
buyer’s performance of all obligations. The buyer hereby appoints any employee, agent, or attorney of seller as buyer’s attorney in fact to endorse and file on
behalf of buyer and UCC from to perfect or record the security interest.
All the information supplied by buyer is correct to the best of the knowledge of the undersigned, and the buyer understands that all goods or services purchased
from seller are subject to all terms and conditions contained in this credit application and agreement and all other terms and conditions contained on any of the
seller’s invoices.
Signed ________________________________________________________________ Title _____________________________________________
Printed Name ___________________________________________________________ Date _____________________________________________
For Office Use ONLY
Acct. ______________________________________ Approved by: ________________________________ Date _________________
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