Legal Name

SS or Fed Tax I.D. No

Billing Street

City

State

Zip Code

Phone

Fax

Cell

Email

Accounts Payable Manager, Phone and E-mail

Please Select Your Business Entity
---SolePartnershipCorporation

State

Year Established

Principal Name/Home Address

Position

Have Your Ever Filed Bankruptcy?

If Yes, Specify

Bank Name

Address

Account #

Phone

Trade References:

Name

Phone

Fax

Email

Applicant agrees that the extension of credit is subject to the following terms and conditions: Net 30 days from the date of shipment. Pallet charges are net 30 days. Invoices in default of these terms are subject to a late payment fee not to exceed 1.5% per month (18% annum). If this account should have to be placed for collection, customer will be responsible for any and all collection and/or legal fees. We certify that all the information submitted by us above is correct and we agree to pay within your terms as stated above. Sole Proprietors, Partners, and Corporate Officers must personally guarantee payment of any and all amounts as may hereafter be owed to Buffalo Concrete Accessories, LLC. by buyer, whether amount exceeds stated credit limits. This shall be a continuing unconditional guarantee and obligates me/us with and to the same extent as buyer, and undersigned expressly waive notice of acceptance of this guarantee. Buffalo Concrete Accessories, LLC. is authorized to collect any reference or bank information listed above for the purpose of establishing credit.

Customer Signature (required)

Date (required)