Sample Credit Application
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Company name
Your name
Title
Street address
Address (cont.)
City
State
Zip code
 Phone
FAX
E-mail
Business Type  Proprietorship  PartnershipCorporation 
Date Established
Business Operates from:ResidenceShopOffice

Name and Address of Principal Owners or Officers

*Name Name
*Title Title
*Home Address Home Address
*Home Phone Home Phone
*SS# SS#

Credit / Trade References

NameName
Address Address
Phone Phone
Bank References
Name  
Address
Phone 
Account #

TERMS: 2% 10th prox. Net 25th.  Past due amounts are subject to the maximum interest rate allowed by state law plus costs of collection including attorney fees and court costs:  Returned materials will be subject to a restocking charge.

The undersigned certifies the above information to be correct,  that it is submitted for the purpose of obtaining credit,  and agrees to all of the terms and conditions of sale of (your co. name).  We also authorize you to inquire of principal trade creditors, banks other credit references to check credit and allow you to answer questions from others about your credit experience with us.  The undersigned certifies the above to be correct, that it is submitted for the purpose of obtaining credit, and agrees to all of the terms and conditions of sale of  (your company name). We also authorize you to inquire of principal trade creditors, banks, other credit references to check credit experience with us.  The undersigned hereby agrees to waive all venue objections.


___________________________________________
Owner / Officer Signature


___________________________________________
Date

___________________________________________
Title

___________________________________________
Witness


PERSONAL GUARANTY

For and in consideration of  (your co. name) extending credit at the request of the undersigned to _________________________________ ("Company"), the undersigned hereby personally guarantees to pay (your co. name) on demand, without offset, any sum which may become due to (your co. name) by the Company whenever the costs of collection including attorney's fees.  It is understood that this guaranty shall be a continuing and irrevocable guaranty and indemnity for such indebtedness of the Company.  The undersigned hereby agree to waive the Homestead exemption, notice of acceptance hereof, notice of presentment, demand, non-payment, dishonor and protest, and consent to and waives notice of any modification, amendment or extension of the terms of credit agreement hereby guaranteed.


___________________________________________
Signature - Individually


___________________________________________
Date

___________________________________________
Signature - Partner or Spouse

___________________________________________
Witness


GUARANTY FOR MEDICAL FORMS

I understand and agree that Health/Accident insurance policies are an arrangement between an insurance carrier and myself.  I also understand that _______________________________ will prepare any necessary reports/forms to help me in making collection from an insurance company and that amount authorized to be paid directly to _______________________________ will be credited to my account on receipt.  However, I clearly understand and agree that all services rendered me will be immediately due and payable.  I paying by credit card, I authorize _______________________________ to put my balance through accordingly.  I also authorize the release of any medical information/records necessary to process my insurance claims.  I now assume liability for all services rendered.  In the event this account needs to be assigned to a collection agency or attorney,  I am aware that I will be responsible for all attorney's fees, collection fees, filing fees, finance charges, interest charges and any other cost incurred.


___________________________________________
Signature


___________________________________________
Date

Disclaimer:  McCabe, Smith, Reynolds & Associates, Inc.  presents no guaranty of any information in this form with regard to the successful collection of debt.  This for is for reference purposes only.   Legal advice should be sought for your individual type of business.