Credit Application for Business Account -
(Secure Form Submission)
* Please review all information required in this form prior to filling in the information. You may need to gather additional data in order to complete and submit the form. You MAY NOT save and return to the form at a later time.
Title *
Company Name *
DNB Number
Phone Number
*
Fax Number *
Email *
Registered Company Address *
City *
State *
Zip Code *
Date Business Commenced
*
Business Type
*
Business Type...
Sole Proprietorship
Partnership
Corporation
Other
Are Purchases Tax Exempt? *
Yes (Upload Signed Exemption Certificate Below)
No
Upload SIGNED Tax Exemption *
Amount of Credit Requested *
Accounting Contact
*
Contact's Phone Number
*
Contact's Fax Number
*
Contact's E-mail *
Bank Name *
Bank Phone Number *
Bank Address *
Bank City
*
Bank State
*
Bank Zip Code
*
Authorized Buyers (Separate Multiple Names with Commas)
*
President/Vice President *
Treasurer/General Manager *
PO/Billing Instructions *
Company Name
*
Address
*
City *
State *
Zip Code *
Phone Number
*
Fax Number
*
Email Address
*
Email Contact's Name *
Company Name
Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
Email Contact's Name
Company Name
Address
City
State
Zip Code
Phone Number
Fax Number
Email Address
Email Contact's Name
1. Payments will be made in accordance with terms stated on each invoice. 1 1/2% per month will be charged on past due balances. If my account is referred to an attorney, for collection, I (we) agree to pay reasonable attorney’s fees and court cost incurred as a result of successful legal action to recover debt. The applicant and the undersigned agree that any litigation hereunder and in connection with the collection of any monies due Creditors shall be brought in the Superior Court of Toombs County, GA and interpreted according to the laws of the State of Georgia being the address of the Creditor extending credit on the Application.
Title and Name *
Date *
Title and Name *
Date
*
*
Hear About Us...
Sales Manager
Internet
Networking
Other
Please List Sales Manager's Name, Search Engine, Networking Contact, or Other.
*
For and in consideration of credit extended or to be extended by U.S. Energy Sciences, Inc., its successors or assignees, and at the request of the undersigned (herein after called “Purchaser”), jointly and severally, do hereby unconditionally guarantee the payment at respective maturity dates of any and all indebtedness of any kind whatsoever, whether now due or which may hereafter become due from Purchaser to U.S. Energy Sciences, Inc., its successors or assignees, and hereby agree to pay punctually such indebtedness, plus interest at the maximum rate allowed by law together with all cost of collection (including reasonable attorney fee), if default in payment thereof be made by Purchaser. The undersigned expressly waive presentment for payment, notice of nonpayment, and protest to any extension of time of payment granted by U.S. Energy Sciences Inc., its successor or assignees. This guaranty contains no limitations or conditions except as written herein, may be modified only in writing signed by the parties hereto, and is to remain in full force and effect until written notices of its termination is received by registered mail by U.S. Energy Sciences, Inc. its successors or assignees, at its office in Vidalia, Georgia, except the written termination of the guaranty by the undersigned shall be effective only at future credit from and after the date of U.S. Energy Sciences, Inc. its successors or assignees, receives aforesaid notice, i.e. any termination hereof as aforesaid shall not affect credits extended prior to its effective termination. Not withstanding any provisions of the Agreement, the aggregate charges to the undersigned for interest, cost of collection, attorney’s fees, and any other charges herein provided for maximum amount allowed by law, such amount is hereby automatically reduced as of inception to an amount that does not exceed the maximum allowed by law. Furthermore, I (we) agree that payments will be made in accordance with terms stated on each invoice, that a service charge of 1½% per month will be charged on past due balances when account is over 30 days past due, and that if my (our) account is referred to an attorney for collection, I (we) agree to pay reasonable attorney’s fee and court cost incurred as a result of successful legal action to recover debt. The applicant and the undersigned agree that any litigation arising hereunder and in connection with the collection of any monies due Creditors shall be brought in the County or Judicial District desired by Creditor.
First Name
Middle Initial
Last Name
SS #
Address
City
State
Zip Code
Phone Number
Birth Date (MM/DD/YY)
Witness's Name
Witness's Signature Authentication
I claim the above name to be my own, and take responsibility for all information submitted within this form.
First Name
Middle Initial
Last Name
SS #
Address
City
State
Zip Code
Phone Number
Birth Date (MM/DD/YY)
Witness's Name
Witness's Signature Authentication
I claim the above name to be my own, and take responsibility for all information submitted within this form.
