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 !!!!!!!