Smiths South-Central Sales Company
Credit Application
INSTRUCTIONS: Please fill out the form below and select the "GENERATE PRINTABLE DOCUMENT" button located at the bottom of the page. You will then be able to print the application and fax/mail it to Smiths South-Central.
-Subject to verification or credit approval-
MAILING ADDRESS
SHIPPING ADDRESS
CITY
STATE
ZIP
PHONE
FAX
EMAIL
WEB ADDRESS
OFFICER/PARTNER/OWNER
SS#
FEDERAL EMPLOYER ID#
RESALE TAX#
(valid only if state certificate attached)
TYPE OF BUSINESS
YEARS IN THIS BUSINESS
CREDIT LINE REQUESTED $
POWER EQUIPMENT DEALER?
YES
NO
BANK REFERENCE
ACCT#
CONTACT
PHONE
FAX
BANK ADDRESS
LIST THREE FIRMS WITH WHOM YOU HAVE AN ACTIVE OPEN ACCOUNT.
1
ADDRESS
PHONE
FAX
CITY/STATE/ZIP
2
ADDRESS
PHONE
FAX
CITY/STATE/ZIP
3
ADDRESS
PHONE
FAX
CITY/STATE/ZIP
**PLEASE FURNISH YOUR MOST RECENT FINANCIAL STATEMENT WITH CREDIT APPLICATION**
HAVE YOU DECLARED BANKRUPTCY IN THE LAST 10 YEARS?
YES
NO
IF YES, WHERE AND WHAT YEAR
YEAR
Our terms are net 10th – Payment is due no later than the 10th of the month following purchase. In the event that any legal action or the services of a collection agency be necessary to collect my account, I agree to pay reasonable expenses incurred, including attorney fees and court costs. I agree to a monthly late charge of one and one-half percent (1 ½%) per month from the due date of every bill until paid.
I certify that everything I have stated in this application and or any attachments are correct. You may keep this application whether or not it is approved. By signing below I authorize you to check my credit and to answer any questions others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes.
Signature: ________________________________ Date:_________________________
CORPORATIONS (Two or more signatures required)
I/We, the undersigned, as officer, owner, agent of the corporation to which credit is being extended, do hereby guarantee the payment of this indebtedness in solido with the corporation.
DATE_________________
NAME______________________________ TITLE__________________________________
NAME______________________________ TITLE__________________________________
After completion, please print and sign the two documents. Fax or mail the application to:
Smiths South-Central Sales Company
1802 South Arkansas Street
Springhill, LA 71075
FAX 800.551.4712