A1 American Credit Application

Newsletter

Date

Company Legal Name

Doing Business As

Phone

Ext

Fax

Billing Address

Street Address

Address Line 2

City

State

Zip Code

Shipping Address

Shipping Address Same as Above

Street Address

Address Line 2

City

State

Zip Code

Parent Company Name

Parent Company Address

Street Address

Address Line 2

City

State

Zip Code

Name of Affiliated Companies

Affiliated Company Address

Street Address

Address Line 2

City

State

Zip Code

Check One

PROPRIETORSHIP

CORPORATION

PARTNERSHIP

OTHER

If OTHER, please specify

Desired Credit Limit

Business Start Date

State of Registration

Federal Tax ID No

Type of Business

Sales Tax Exempt?

Yes

If Yes, please attach valid Sales Tax Certificate

Choose File

Do You Require a Purchase Order?

Yes

COMPANY CONTACT INFORMATION

Primary Company Contact

Phone

Ext

Fax

Accounts Payable Contact

Phone

Ext

Fax

CORPORATE OFFICERS, MEMBERS, PARTNERSHIP OR PROPRIETORSHIP INFORMATION

Principal’s Name

Title

Principal’s Name

Title

Principal’s Name

Title

Principal’s Name

Title

BANK REFERENCE INFORMATION

Bank Name

Contact Name

Phone

Ext

Address

Street Address

Address Line 2

City

State

Zip Code

Checking Account #

Saving Account #

COMPARABLE VENDOR REFERENCE INFORMATION

Vendor Name

Account #

Address

Street Address

Address Line 2

City

State

Zip Code

Phone

Ext

Fax

Vendor Name

Account #

Address

Street Address

Address Line 2

City

State

Zip Code

Phone

Ext

Fax

Vendor Name

Account #

Address

Street Address

Address Line 2

City

State

Zip Code

Phone

Ext

Fax

W-9 Form

DOWNLOAD W-9 FORM HERE

*PLEASE NOTE: You must download, complete, sign, and upload the W-9 document with this credit application. Any application without a W-9 form will not be processed.

W-9 File Upload

Choose File

TO BE READ AND COMPLETED BY ALL APPLICANTS

Has the Applicant filed for bankruptcy, or been the subject of an involuntary bankruptcy petition, in the past 10 years?

Yes

Have any unsatisfied judgment(s) been entered against Applicant in the past 7 years?

Yes

Have any tax lien(s) been filed against the Applicant in the past 7 years?

Yes

If the answer to any one or more of the foregoing questions is “yes”, please attach an explanatory statement.

APPLICANT CERTIFICATION.

By signing below, (a) I, on behalf of my business (the “Applicant”), hereby request credit from the company(ies) selected above (each, a “Creditor”) for the purpose of financing the Applicant’s purchase of goods from Creditor; (b) I authorize Creditor to investigate the Applicant’s creditworthiness, including without limitation by obtaining credit reports and other information, and to share such information with any Creditor or affiliate of a Creditor or any third party in connection with this application or any credit extended by Creditor to Applicant; (c) I authorize all of Applicant’s past and present banks, lenders, lessors, landlords, trade creditors and other creditors to provide Creditor or its designee with any and all information that will assist Creditor in its credit inquiry; and (d) I certify that all information provided in this application about the Applicant and myself is accurate and complete. This application is given for the purpose of obtaining credit. Applicant agrees that, if credit is extended in response to this application, the terms and conditions applicable to such credit shall be as set forth in between Applicant and Creditor(s), and may be amended from time to time.

OFFICER/PARTNER CERTIFICATION. By signing below, (a) I certify that I am authorized on behalf of the Applicant to apply for credit for the Applicant, and (b) I authorize Creditor to verify credit and other information about me relevant to this application, and to obtain consumer report(s) about me from consumer reporting agencies.

GUARANTOR AUTHORIZATION. By signing below, (a) I certify that all of the information about me provided in this application is accurate and complete, and (b) I authorize Creditor to verify credit and other information about me relevant to this application, and to obtain consumer report(s) about me from consumer reporting agencies.

IMPORTANT LEGAL NOTICES The term “me” in these Notices refers to an officer or guarantor of Applicant, who has signed this application, or to the Applicant if Applicant is a sole proprietor who has signed this application, or to a partner in Applicant who has signed this application if Applicant is a partnership.

Company Name

STATEMENT OF TERMS

Seller establishes, in the name of the applicant, subject to approval, an open account for the purchases of goods from Seller in accordance with the terms and conditions listed below. The terms set forth herein shall apply to sales from any A1 American, and shall continue until the undersigned cancels this agreement in writing. The Undersigned authorizes any bank, credit reporting agency, or credit references to release Undersigned’s individual and/or company credit information to Seller. Seller may check credit references as often as it deems necessary. The Undersigned expressly agrees to pay interest/finance charges on any past due amounts at the rate of 1.5% per month. The Undersigned further agrees to pay all reasonable collection costs and/or court costs and/or attorney fees incurred in connection with the collection of this account. Merchandise returned is subject to a 15% restocking fee, and all merchandise tendered for return is subject to inspection. No credit will be allowed for damaged, mutilated, altered, obsolete, or otherwise unsaleable merchandise.

Print Name *

First Name

Last Name

Signature

Sign Here

(OFFICER/PARTNER/MEMBER/SOLE PROPRIETOR)

ELECTRONIC SIGNATURE AGREEMENT - by signing this credit application agreement, you will be entering into an electronic agreement, evidenced by an electronic record. You will also be consenting to the use of an electronic signature to manifest your agreement to the terms and conditions in the credit application terms. This consent is limited to that particular transaction and does not apply to any future transactions entered into by you and A1 American. You must electronically acknowledge that you have read these disclosures and agree to all terms.

Date

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