Credit Application

Company Name: * Email Address:
Street Address: * Date Established:
City: * Business Type

County:    
State: *    
Zip: * Kind of Business:
Telephone: * Website Address:
Fax:    
Resale Certificate #: *
We also require a signed
and completed resale certificate. (Follow link after submitting this form)
Exp. Date(If Applicable):
Accounts Payable Contact Name: * Phone #: * *
Type of Credit Desired * :  
   
   
  Estimated Monthly Purchases

Bank Info not required for Charge card accounts
Bank Name: * Account #: * Type: *
Address: Account #: Type:
City: *
State: * Phone:
Zip: Fax:
I have maintained a satisfactory checking account with this bank for years.

For Sole Owner/Partnership, please provide the following information:
Owner Name: Owner's Social Security Number:
Owner's Address: * Owner's Driver's License Number: *
City: *
State: * Phone:  
Zip: *
Name of parent company, if subsidiary:

Partners or Officers if Incorporated:
Name: Home Address:
Name: Home Address:

Vendor References (give names of those you buy from on an open account or (COD/CCA) basis:
Name:
Address:
City:
State:
Zip:
Phone:
Fax*(Required):
Acct #:
Name:
Address:
City:
State:
Zip:
Phone:
Fax*(Required):
Acct #:
 
Name:
Address:
City:
State:
Zip:
Phone:
Fax*(Required):
Acct #:
Name:
Address:
City:
State:
Zip:
Phone:
Fax*(Required):
Acct #:

Credit Card Information
Credit Card #: * ---
Exp Date: * /
3 digit Security Code What is this? *
Name: *
Street Number of Billing Address: *
Billing Zip Code: *
We also require a signed and completed charge card authorization form. (Follow link after submitting this form)

Website Information
Would you like website access?
If so, what would you like to use as a password? *

I certify that the above information is true and correct to the best of my knowledge. By clicking the "Submit Application" button at the end of this paragraph, I give authority to the Electric Sweeper Service Company to gather any necessary credit and reference information on my behalf for the sole purpose of determining credit worthiness. I recognize that by submitting this form for credit approval that I agree to maintain my account according to the terms established and I will remain liable for any collection or interest costs should my account become delinquent.

If applying for charge card terms, I understand that by clicking "Submit Application" , I give Electric Sweeper Service Company my permission to charge my credit card for parts and/or machine purchases that I make.

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