Apply for Account - Champion Soap & Supply

Commercial Credit Application:

Your Name:
E-mail Address:
Company Info
Company Name:
Address:
P.O. Box:
City:	State: Zip:
Phone #:	Fax #:

Nature of Business:
President:	Type of Business:
Check here if you require a Purchase Order.

Shipping Info
Check here if same as above.
Company Name:
Address:
P.O. Box:
City:	State: Zip:
Phone #:	Fax #:

Bank Reference
Bank Name:
Address:
P.O. Box:
City:	State: Zip:
Phone #:
Account Rep:

Credit References Please include Company Name, Address, City, State, Zip and Phone for each
Reference #1:

Reference #2:

Reference #3:

Additional Information

Please list those persons authorized to use this account:

If you are tax exempt, we require a copy of the certificate.
We require a fifty dollar minimum order.
We offer no discount.
All accounts are payable within thirty (30) days after the date on invoice.
The buyer agrees to pay a service charge on past due balances,
not to exceed (1 1/2%) per month, eighteen percent (18%) annually.

Monthly Credit Desired: $

Has your company or any of its owners , partners or offices ever filed a voluntary petition in bankruptcy, adjudged bankrupt or made an assignment for the benefit of creditors?
Please select: Yes or No
If yes, please explain:

Have you ever applied for credit with our company in the past?
Please select: Yes or No
If yes, please explain:

The above items are fully understood and accepted. By entering my name in the box below, I accept personal liability for financial obligations incurred as the result of receiving credit from Champion Soap & Supply Corp.

Name:
Date:

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