Application for credit Click here to download the original file

FIRM NAME  _____________________________________________________________________________________   Date  __________________

Name of Parent Company if Subsidiary  ______________________________________________________________________________________________________

BUSINESS ADDRESS  ___________________________________________________________________________               Yrs. at address ____________________

___________________________________________________________________________               Yr. Established  __________________

    Phone (         )    __________________ FAX   (         )    __________________ E-mail address ______________________________________

 TYPE OF BUSINESS     ____________________________________________________________  Corp __________ Partnership __________ Sole Prop __________

 PRINCIPALS                   Name  ____________________________________________________________________                 Title  __________________________

 Home Address  _____________________________________________________________                 Soc. Sec. #  _____________________

 _____________________________________________________________                 Driv. Lic # _____________________

 Name  ___________________________________________________________________                  Title  __________________________

Home Address  ____________________________________________________________                  Soc. Sec. #  _____________________

 ____________________________________________________________                   Driv. Lic. #  _____________________

 Reference: COMMERCIAL CHECKING ACCT. carried at ( Name of bank ) ________________________________________________________________________

 Address   _____________________________________________________________________________________   Acct #  _________________________

 Phone #  (          )  ____________________________           FAX #  (          ) ______________________________     Contact _________________________ 

 REFERENCES :   ( Give only names of those you buy from with an open account )

 Name  _____________________________________________________________________________________Phone (          ) ___________________

Complete Address  _______________________________________________________________________FAX   (          ) _______________________

Name  _________________________________________________________________________________________                 Phone (          ) ___________________

Complete Address  ______________________________________________________________________   FAX    (         )________________________

Name  ______________________________________________________________________________________ Phone  (          ) __________________

Complete Address  ______________________________________________________________________FAX    (          )  ______________________

Name  _____________________________________________________________________________________ Phone  (          ) __________________

Complete Address  ______________________________________________________________________ FAX     (         ) _______________________

The above information is given for the purpose of obtaining credit privileges on a NET 10 th  following month charge account and shall be regarded as true and correct.

I understand and agree that accounts are to be settled in full each month or a 1 ½ % service charge will be added monthly.

Authorized Signers : Name _____________________________________    Signature  ____________________________________  Driv Lic #__________________

 Name _____________________________________    Signature  ____________________________________  Driv Lic #  _________________

 Name  _____________________________________   Signature  ____________________________________  Driv Lic #  _________________

Name  _____________________________________   Signature _____________________________________  Driv Lic # _________________

 Is a  P.O. No. Required ?   Yes  ______   No  ______                                                 Please attach a business card with application

Liability Insurance Carrier :        please send us a copy of a certificate of insurance for “general liability” and “auto” for  truck rental

We highly recommend that you add us as additionally insured to your gen liab/auto with respects to rented and leased equipment to protect you properly.

I, the undersigned, personally guarantee to pay the balance, interest and collection fees in full of any contracts authorized by this business. I authorize Simon Equipment to contact my bank as a credit reference.

SIGNED BY Owner or 2 Officers   _____________________________Print name & title    _________________________________

Officer     _____________________________Print name & title    _________________________________ THIS MUST BE FILLED OUT COMPLETELY   !!!!!!!