Green Supply, Inc. Robert L. Green 3059 Audrain Road 581 - Vandalia, MO 63382 - (573) 594-6771 or (573) 594-6173 Fax (573) 594-2211 CUSTOMER CREDIT APPLICATION Business Information Full Legal Name of Business _____________________________________________ Full Trade Name of Business _____________________________________________ Mailing Address of Business _____________________________________________ Street Address of Business (No P.O. Box) ________________________________ Telephone Number _____________________________________________________ Fax Number _____________________________________________________ E-mail Address _____________________________________________________ E-mail Specials/Updates? Yes ___ No ___ What is the purpose of your business (what do you do)? _____________________ _____________________________________________________________________________ How long has your business been in existence? _____________________________ PERSONAL INFORMATION Name of individual in charge of business (Last, First, Middle, Suffix) _____ _____________________________________________________________________________ Social Security Number of individual _____________________________________ Residential address of individual _____________________________________ How long have you lived at above residence? _____________________________ If less than three years, list previous address _____________________________ Drivers License Number _____________________________________________ Position Held within the Business _____________________________________ GENERAL INFORMATION What is the credit limit you are requesting? _____________________________ What is your anticipated monthly volume? _____________________________ Are you purchasing for resale? _____________________________________________ Who do we contact if there is a problem with an invoice? Name: ____________________________________________________________ Phone Number: ____________________________________________________________ Who is the authorized purchaser for your business? __________________________ _____________________________________________________________________________ REFERENCE INFORMATION BANK REFERENCE Name and Branch of Business Bank _____________________________________ Contact Person at the Bank _____________________________________ Phone Number of Branch _____________________________________ Account Number with Bank _____________________________________ Trade References (list 4 or 5) 1. Company Name __________________ Account Number _______________ Phone Number __________________ Fax Number ___________________ Contact Person _____________________________________________________ 2. Company Name __________________ Account Number _______________ Phone Number __________________ Fax Number __________________ Contact Person _____________________________________________________ 3. Company Name __________________ Account Number _______________ Phone Number __________________ Fax Number __________________ Contact Person _____________________________________________________ 4. Company Name __________________ Account Number _______________ Phone Number __________________ Fax Number __________________ Contact Person _____________________________________________________ 5. Company Name __________________ Account Number _______________ Phone Number __________________ Fax Number __________________ Contact Person _____________________________________________________ 6. Company Name __________________ Account Number _______________ Phone Number __________________ Fax Number __________________ Contact Person _____________________________________________________ ** INCLUDE FINANCIAL STATEMENT WITH APPLICATION ** _____________________________________________________________________________ CREDIT APPLICATION COMPLETE THIS SECTION ONLY IF REQUESTING OPEN ACCOUNT FOR BILLING!!! TERMS AND CONDITIONS 1. Payment terms are net due from date of invoice. 2. All amounts not paid as agreed herein shall accrue interest at the rate of 1 1/2 % per month (18% per annum) or the highest permissible rate by law, whichever is less. 3. Applicant agrees to pay a service charge of $25.00 for each check returned unpaid. 4. In the event of default of payment of any amount due hereunder, and if the account is placed with an outside attorney for collection, Applicant agrees to pay all reasonable collection costs, attorney fees and court costs. 5. No returns will be accepted without prior return authorization number. In order to induce Green Supply, Inc. to grant me credit, I give permission for my credit to be checked as required for that purpose. Owner of Business ___________________ Date _________________ Joint Owner of Business ___________________ Date _________________ PERSONAL GUARANTEE I hereby agree to pay Green Supply, Inc. all indebtedness now or hereafter owing by me to said company, whether individually, partnership or corporation. In consideration of Green Supply, Inc. extending credit to the above applicant, the undersigned does hereby individually and personally guarantee the sum or sums of money as may at anytime hereafter become due from the said applicant for goods sold to the applicant whether said indebtedness be in the form of notes, bills or open account. If it becomes necessary to enforce this guarantee by suit, I agree to pay interest and attorney fees as allowed by law. Date ____________ Signature of Owners x_________________________________ Date ____________ Signature of Owners x_________________________________ Office Use Only Customer # _________________ App. For: OA ____________________ Co. Check ____________________ Date Received __________________ Date Sent ____________________ Approved By __________________ For ____________________ Date __________________