BILL TO:                     FIRM NAME                                                                            BILL TO:                    
                           

ADDRESS:

CITY:

STATE:      ZIP CODE:             
       

NATURE OF BUSINESS:

 

 

 

BILL TO:                     FIRM NAME SHIP TO: PHONE NUMBER:
(          )
ADDRESS: STREET ADDRESS: FAX NUMBER:
CITY, STATE, ZIP: CITY, STATE, ZIP: SOCIAL SECURITY OR FEDERAL EID NO:
NATURE OF BUSINESS: CIRCLE ONE:                       SUBSIDIARY             DIVISION               AFFILIATE
 
NAME:
ANTICIPATED ANNUAL PURCHASES:
BUSINESS TYPE (CIRCLE ONE):

      CORPORATION          PROPRIETORSHIP          PARTNERSHIP
No. of Employees
at this location:
Years in Business: Present Management:

                                           YRS.
Is a Financial Statement available:

____________ YES   ____________ NO
                                     
PRINCIPALS IN THE BUSINESS
                                     
NAME:                                                                                                                                                  TITLE:

1
NAME:                                                                                                                                                  TITLE:

2
ACCOUNTS PAYABLE CONTACT: NAME OF CHIEF FINANCIAL OFFICER:
                                     
BANK REFERENCES
                                     
NAME: ADDRESS: CITY, STATE, ZIP:
CONTACT PERSON: ACCOUNT NUMBER: PHONE
(          )
                                     
TRADE REFERENCES
                                     
NAME:

1
ADDRESS: CITY, STATE, ZIP: PHONE NUMBER:
(          )
NAME:

2
ADDRESS: CITY, STATE, ZIP: PHONE NUMBER:
(          )
NAME:

3
ADDRESS: CITY, STATE, ZIP: PHONE NUMBER:
(          )
                                     
SALES EXEMPTION CERTIFICATE
                                     
The undersigned purchaser being fully informed concerning the applicable sales tax act and their rules and regulations, hereby claims to be legally entitled to exemption from such taxes on all articles of tangible personal property purchased from Landmark Systems, Inc. by reason of one or more classifications checked.
                                       
  Resale State   License No.         Firm Name:                
  Industrial Processing                              
  Government Unit             Signature:                
  Non-Profit Institution                              
  Other (must specify)             Title:                
                                       
IF YOUR SPECIFIC STATE REQUIRES IT'S OWN FORM, PLEASE ATTACH A COPY.
                                     
TAXABLE SALES
                                     
STATE:       COUNTY:         STATE:                 SALES TAX % APPLICABLE:    
                                       
                                     
                                     
SIGNATURE:               TITLE:             DATE:      
                                     
THIS APPLICANT AUTHORIZES THE ABOVE CREDITOR TO OBTAIN CREDIT REPORTS FROM ANY CREDIT REPORTING AGENCY. THIS APPLICANT FURTHER AUTHORIZES ANY BANK OR COMMERCIAL BUSINESS WITH WHICH THE APPLICANT IS DOING OR HAS DONE ANY TYPE OF BUSINESS TO GIVE ANY AND ALL NECESSARY INFORMATION TO THE CREDITOR WHICH WILL ASSIST THE CREDITOR IN THE CREDIT INVESTIGATION. THE APPLICANT FURTHER AUTHORIZES THE CREDITOR TO REINVESTIGATE THE APPLICANTS CREDIT STATUS FROM TIME TO TIME AS THE CREDITOR DEEMS NECESSARY. IN MAKING THIS APPLICATION FOR CREDIT, THE CUSTOMER AGREES TO PAY ALL INVOICES WITHIN 30 DAYS FROM DATE OF INVOICE AND TO PAY A SERVICE CHARGE OF 1 1/5% PER MONTH, WHICH IS AN ANNUAL PERCENTAGE RATE OF 18% ON ALL OVERDUE BALANCES. IN THE EVENT A SUIT IS NECESSARY TO COLLECT ANY AMOUNT, THE CUSTOMER AGREES TO PAY THE SELLERS'S REASONABLE ATTORNEY'S FEES FOR APPEAL.
                                       
OFFICE USE ONLY:         Customer Number:      Approval Code:          Credit Limit:          Date:    
                                     

 

 

 

 

 

 

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Credit Application Page - Pubpagbyrpg Org 010101 Revision 08/30/12 Rev A