ACS
6233 East Sawgrass Road
Sarasota, Florida 34240-8922
E-Mail: Sales
Phone (941)377-5775 -- Fax (941)378-4226
After reviewing our Terms
and Conditions, please print out this Credit
Application as you see it here. Be aware that the size of the
font that you have selected for your browser may affect the size
of the printed output; we suggest a medium font. Alternatively,
you may download the form online in the PDF format. Please fill
in the Application completely, fax it to us and then follow up by
mailing the signed, original to us at the above address. Please
contact us if you have any questions.
Today's Date:________________
Name and Address Information (Please type or print)
Name: ________________________________________
Company:_____________________________________________________
Address:______________________________________________
City:_________________________________________________
State/Province:______________________________
Zip/Postal Code:_____________________________
Country:_____________________________
Phone:______________________________
Fax:________________________________
E-mail:_______________________________________________
Billing Address (if different than above)
Attn:______________________________________________
Address:______________________________________________
City:_________________________________________________
State/Province:______________________________
Zip/Postal Code:_____________________________
Country:____________________________
Phone:______________________________
Fax:________________________________
E-mail:_______________________________________________
Name and Address of Parent Company
Name:_________________________________________________
Title:________________________________________________
Parent Company:______________________________________________
Address:______________________________________________
City:_________________________________________________
State/Province:______________________________
Zip/Postal Code:_____________________________
Country:____________________________
Phone:______________________________
Fax:________________________________
E-mail:_______________________________________________
About Your Business
Type of Business: ________________________________________________________________
__________________________________________________________________________________
Years in Business _________ Current Gross Sales ______________ Net Worth ________________
No. of Employees _________
Authorized Buyer's Name ______________________________ Title _________________________
Authorized Buyer's Name ______________________________ Title _________________________
Authorized Buyer's Name ______________________________ Title _________________________
Banking
Type of Account (Please circle choices) Checking - Loan - Savings
Bank Name _____________________________________ Acct. No. ________________________
Address ________________________________________ Contact __________________________
City, St, Zip ______________________________________ Phone __________________________
Type of Account (Please circle choices)
Checking - Loan - Savings
Bank Name _____________________________________ Acct. No. ________________________
Address ________________________________________ Contact __________________________
City, St, Zip ______________________________________ Phone __________________________
Trade References
Name _________________________________________ Acct. No. _________________________
Address _______________________________________ Contact ___________________________
City, St, Zip __________________________________ Phone ______________________________
Name _________________________________________ Acct. No. _________________________
Address _______________________________________ Contact ___________________________
City, St, Zip __________________________________ Phone ______________________________
Name _________________________________________ Acct. No. _________________________
Address _______________________________________ Contact ___________________________
City, St, Zip __________________________________ Phone ______________________________
I/we certify that all information provided on this application is true, complete and accurately represents my/our present financial condition and is furnished with the sole purpose of securing credit from ACS. I hereby authorize ACS or its Agents to obtain credit reports and verify any of the information provided from whichever sources it deems necessary. If credit is extended, I/we agree to make payment within thirty (30) days of invoice date. I/we understand that a past due charge may suspend credit sales and that a 1 1/2 percent per month service charge will be added to the unpaid balance. I/we also understand that in the event it becomes necessary to refer this account to an attorney or any collection agency that I/we will be responsible for any and all fees associated or connected with said collections. I/we hereby guarantee the payment of such debts and agree that ACS shall hold myself/ourselves personally responsible for all charges associated with same.
X______________________________________ X______________________________________
Name/Title/Date ___________________________ Name/Title/Date ____________________________
__________________________________________________________________________________
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