Copy and paste into box above then fill out information..or print and fax .Please print clearly
Date: Account # Sales Rep.
Business Name:
Street Address:
City: State: Zip Code
Business is (Please Circle) Sole Proprietorship - Partnership - Corporation - Other
Type of Business: Own or Rent Building:
Person Responsible for Payments:
E-Mail Address:
Phone #: Federal Tax ID #:
Sales Tax Resale Certificate #:
1. 2.
Name(s) of Principal(s): ____________________ _______________________
Home Address: ____________________ _______________________
____________________ _______________________
Phone # (Residence): ____________________ _______________________
Occupation: ____________________ _______________________
Social Security #: ____________________ _______________________
Address(es) of
Real Estate Owned: ____________________ _______________________
Names on Title: ____________________ _______________________
Name & Address of
Other Business Owned: ____________________ _______________________
Our Credit Data is reported to Experian, a credit services company. The undersigned authorizes credit inquiries. If
granted, credit privileges may be withdrawn at any time.
Credit References:
Supplier Supplier
Name: ______________________ _____________________
Address: ______________________ ______________________
City, State: ______________________ ______________________
Phone #: ______________________ ______________________
Bank Bank
Name: ______________________ ______________________
Address: ______________________ ______________________
City, State ______________________ ______________________
Phone #: ______________________ ______________________
Credit Policy: Past due balances are subject to a finance charge of 1.5% per month which is an annual percentage
rate of 18%.
I certify that all information on this form is correct. I fully understand your credit terms and the undersigned personally
guarantees proper payment in consideration of extended credit. This is a continuing guaranty relating to any indebtedness,
including that arising under successive transactions. I hereby agree to bind myself personally and on behalf of my company
to pay you on demand any sum which may come due to you by the business whenever the business shall fail to pay same.
If deemed necessary to retain an attorney to enforce this agreement, or to collect any past due account hereunder, then,
whether or not suit is brought, I shall pay: 1. A FINANCE CHARGE OF 1.5% PER MONTH, WHICH IS AN ANNUAL RATE
OF 18% 2. All costs and expense incurred including a reasonable attorney’s fee. All costs and expenses shall be included
in the judgment and shall be secured by any liens. Guarantor waives all defenses of notice, presentment and demand.
( 1 ) Personal Guarantor
Signature: Date:
Print Name:
( 2 ) Personal Guarantor
Signature: Date:
Print Name:
Witness: Date:
Print Name:
Web Site Order Entry:
PIN/PASSWORD:___________________________________
Please create a three to five digit combination of letters and numbers as your pin / password
E MAIL ADDRESS______________________________________________________
There is a 24 hour waiting period before your web account is activated. You will receive confirmation by e-mail that your
account is activated.
INTERNAL USE ONLY
Date: ____________________________________________________
Account Name: ____________________________________________________
Type Account: ____________________________________________________
Credit Limit ____________________________________________________
Current Balance: ____________________________________________________
Overdue Balance: ____________________________________________________
Credit Terms: ____________________________________________________
Days Out Of Terms: ____________________________________________________
Comments: ___________________________________________________
____________________________________________________
Credit Terms Date:
Additional Information
____________________________________________________
___________________________________________________
FAX To 978-373-9817
Application Distributed By: Date:
Assigned Sales Representative: Date: Revised: 09/18/09
Date: Account # Sales Rep.
Business Name:
Street Address:
City: State: Zip Code
Business is (Please Circle) Sole Proprietorship - Partnership - Corporation - Other
Type of Business: Own or Rent Building:
Person Responsible for Payments:
E-Mail Address:
Phone #: Federal Tax ID #:
Sales Tax Resale Certificate #:
1. 2.
Name(s) of Principal(s): ____________________ _______________________
Home Address: ____________________ _______________________
____________________ _______________________
Phone # (Residence): ____________________ _______________________
Occupation: ____________________ _______________________
Social Security #: ____________________ _______________________
Address(es) of
Real Estate Owned: ____________________ _______________________
Names on Title: ____________________ _______________________
Name & Address of
Other Business Owned: ____________________ _______________________
Our Credit Data is reported to Experian, a credit services company. The undersigned authorizes credit inquiries. If
granted, credit privileges may be withdrawn at any time.
Credit References:
Supplier Supplier
Name: ______________________ _____________________
Address: ______________________ ______________________
City, State: ______________________ ______________________
Phone #: ______________________ ______________________
Bank Bank
Name: ______________________ ______________________
Address: ______________________ ______________________
City, State ______________________ ______________________
Phone #: ______________________ ______________________
Credit Policy: Past due balances are subject to a finance charge of 1.5% per month which is an annual percentage
rate of 18%.
I certify that all information on this form is correct. I fully understand your credit terms and the undersigned personally
guarantees proper payment in consideration of extended credit. This is a continuing guaranty relating to any indebtedness,
including that arising under successive transactions. I hereby agree to bind myself personally and on behalf of my company
to pay you on demand any sum which may come due to you by the business whenever the business shall fail to pay same.
If deemed necessary to retain an attorney to enforce this agreement, or to collect any past due account hereunder, then,
whether or not suit is brought, I shall pay: 1. A FINANCE CHARGE OF 1.5% PER MONTH, WHICH IS AN ANNUAL RATE
OF 18% 2. All costs and expense incurred including a reasonable attorney’s fee. All costs and expenses shall be included
in the judgment and shall be secured by any liens. Guarantor waives all defenses of notice, presentment and demand.
( 1 ) Personal Guarantor
Signature: Date:
Print Name:
( 2 ) Personal Guarantor
Signature: Date:
Print Name:
Witness: Date:
Print Name:
Web Site Order Entry:
PIN/PASSWORD:___________________________________
Please create a three to five digit combination of letters and numbers as your pin / password
E MAIL ADDRESS______________________________________________________
There is a 24 hour waiting period before your web account is activated. You will receive confirmation by e-mail that your
account is activated.
INTERNAL USE ONLY
Date: ____________________________________________________
Account Name: ____________________________________________________
Type Account: ____________________________________________________
Credit Limit ____________________________________________________
Current Balance: ____________________________________________________
Overdue Balance: ____________________________________________________
Credit Terms: ____________________________________________________
Days Out Of Terms: ____________________________________________________
Comments: ___________________________________________________
____________________________________________________
Credit Terms Date:
Additional Information
____________________________________________________
___________________________________________________
FAX To 978-373-9817
Application Distributed By: Date:
Assigned Sales Representative: Date: Revised: 09/18/09
All rights reserved. US Eco Products Corporation,US Eco Friendly Products Corporation, USEcoProducts.com 2009-11 Copyright
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USEcoProducts.com
US Eco Products Corporation
| To provide Environmentally Green Eco Friendly, Eco Safe Business to Business products |
