application

Edward Wayne Industries
10308 Metcalf # 308
Overland Park, KS 66212
Fax (816) 943-8601

Application for Charge Account
Please fill in the form below.
Then, print this page and mail or fax the information to us.

Business Name:

Billing Address:

City, State & ZIP:

Complete Shipping Address:

Phone: Fax:

Contact Person/Title:

Type of Business:

Individual Partnership Corporation

State of Incorporation:

Tax Exempt Number:

Federal ID Number:

Restrictions on use of Account:

Authorized Person on Account/Title:

Purchase Order Number

Please list any further requirements for payment of invoice:

Name of Bank:

Bank Address:

Bank Phone:

Bank Contact/Title:

References:

Reference #1: {Name / Address / Contact Person / Phone}

Reference #2: {Name / Address / Contact Person / Phone}

Reference #3: {Name / Address / Contact Person / Phone}

Terms:

ACCOUNTS NOT PAID WITHIN 60 DAYS, FOLLOWING THE DATE OF INVOICE, WILL BE PLACED ON C.O.D. BASIS, UNTIL THE ACCOUNT IS BROUGHT CURRENT. IN ADDITION, INTEREST WILL BE ADDED AT 1 _ % PER MONTH (18% ANNUALLY ) ON ALL OUTSTANDING INVOICES OVER 30 DAYS OLD.

ACCOUNTS THAT ARE REPEATEDLY PAST DUE, WILL BE PLACED ON A PERMANENT C.O.D. BASIS.

List names of Partners, Owners and/or Officers of the Corporation.

READ CAREFULLY BEFORE SUBMITTING:

The information given on this application is complete and correct to the best of my knowledge. Edward Wayne Industries may conduct a reasonable credit investigation for myself, my business, or my organization. I agree to notify Edward Wayne Industries in writing within seven days of any changes in my account number, address, or liability. I understand that all inquiries and records are maintained in strict confidence and in compliance with the Fair Credit Reporting Act of 1971, and the Equal Credit Opportunity Act of 1975.

Signature:_________________________________________ Date:_____________

Position/Title:_____________________________________