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					                                                                                           Verde Valley Hardware
                                                                                                     th
                                                                                           545 S 12 St
                                                                                           Cottonwood, AZ 86326
                                                                                           Phone (928) 634-7868
                                                                                           Fax (928) 634-1381

                            Business Credit Application

  PLEASE READ THE FOLLOWING BEFORE FILLING OUT APPLICATION:
  Please print, all must be completed in full to establish credit terms. We are only accepting large
  business accounts. For smaller business or personal accounts you can place a deposit down
  (your credit limit is determined by your deposit). Accounts (except those with deposit) with
  under $200 in purchases per year will be subject to closure. Arizona Form 5000 must also be
  completed for tax exempt accounts. It may take up to 45 days for application to be approved.


Legal Name of Applicant
Street Address
City, State, Zip
Telephone Number                 (     )       -                               Fax Number (               )    -
                                Sole Prop.           Partnership           Corporation
No. of Employees               Years in Operation                    Approx Annual Sales
Federal Identification Number (required for account)

Credit Limit Amount
 Desired Credit Limit: _____________
 If your application does not meet our house account requirements, are you willing to put down a
 deposit to open an account? (circle one) Y N


Sales Tax Exemption Certificate
 Sales Tax Exemption Certificate Number: _______________________
 Please attach a copy of your certificate and Arizona Form 5000 with application for tax exemption

Type of Business
Please describe what type of business this account is for.




For the purpose of establishing credit terms, the above applicant furnishes the following bank and trade references.

Bank References (required if not putting down a deposit)
 Name                                                        Telephone No.        (    )     -
 Address                                                     Account Number
 City/St/Zip                                                 Bank Officer

                                                             Over
Trade References (required if not putting down a deposit)
 Name                                                             Name
 Address                                                          Address
 City/St/Zip                                                      City/St/Zip
 Telephone No.           (     )       -                          Telephone No.          (    )      -
 Fax Number              (     )       -                          Fax Number             (    )      -

 Name                                                             Name
 Address                                                          Address
 City/St/Zip                                                      City/St/Zip
 Telephone No.           (     )       -                          Telephone No.          (    )      -
 Fax Number              (     )       -                          Fax Number             (    )      -


Authorized Signatures
In order to charge on your account we will need a list of all authorized person. Be sure to include yourself. We
may require a current Arizona driver’s license for positive identification. The applicant is responsible for
updating us with current names that may charge to the account. If a name is not on the list or the person
cannot be identified no charges will be accepted.

 Names
 (please print)




Important Note: The above must be completed in full to establish credit terms. Customer will receive invoice at time of purchase, a fee
may apply if additional copies are needed. In absence of any special terms offered, it is understood that payment will be due 15 days
from date of statement. A 2.0% monthly (24% APR) service charge may be added to all delinquent accounts. If delinquent payment
makes placement for collection necessary, customer will be responsible for all collection expenses as well as responsible attorney fees
and court costs incurred by Verde Valley Hardware, L.L.C. My signature below indicates that I/we understand, accept, and will comply to
these terms, and allow Verde Valley Hardware to investigate our credit history.

 X                                                                                   Date :
 Signature & Title (Required to process application)



 Name and Title of Person Responsible for Payment

				
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