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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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