CONFIDENTIAL CREDIT APPLICATION

Date*

Terry Supply Sales Rep:

Customer Type:*

Industrial

Medical

Bulk CO2

CO2

Business Entity:

Partnership

Corporation

LLC

Type of Business:*

Tax Status*

Taxable

Tax-Exempt*

*Tax Exempt Certificate must be attached.

Tax Exempt Certificate Upload

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Account Name:*

Firm Principals:

President*

President

Vice President*

Vice President

Treasurer/Controller*

Treasurer/Controller

Accounts Payable*

Accounts Payable

Billing Address*

Street Address

Billing City*

City

Billing State*

State

Billing ZIP*

Zip Code

Shipping Address

Shipping Address*

Street Address

Shipping City*

City

Shipping State*

State

Shipping ZIP*

Zip Code

Business Phone*

Business Fax

Business Cell

Principal Email Address:

Email*

I would like my Invoices and Statements emailed:
Email addresses will not be sold or subject to junk/unwanted email

Email Invoices*

Yes

Trade References: 3 Required

Trade Reference #1*

Business Name | Point of Contact | Account Number | Email or Fax Number

Trade Reference #2*

Business Name | Point of Contact | Account Number | Email or Fax Number

Trade Reference #3*

Business Name | Point of Contact | Account Number | Email or Fax Number

AGREEMENT TO TERMS AND CONDITIONS

Invoices are due Net 30 after the date of purchase. All invoices past due will be assessed a finance charge at the rate of 18% per annum, which is 1.5% per month until the balance is paid in full. If collection is made by suit or otherwise, I / We agree to pay collection costs, including but not limited to attorney fees and hereby waive all rights to claim exceptions under all state laws.

I / We the undersigned (if Corporation, the Corporate/Agent) hereby state that the foregoing agreement to terms and conditions are agreed upon and that the information of this application is true and correct.

Company Name*

Sales Tax Exemption #*

Authorizing Agent:*

Owner, Partner, Corporate Officer/Agent

Authorizing Agent Title:*

Authorization:*

I hereby authorize the above listed references to release information requested of them necessary to establish a line of credit.

2nd Authorizing Agent:

Owner, Partner, Corporate Officer/Agent

2nd Authorizing Agent Title:

Authorization:

I hereby authorize the above listed references to release information requested of them necessary to establish a line of credit.

PERSONAL GUARANTEE

In consideration of any credit extended, the undersigned will personally guarantee full and prompt payment of all indebtedness of incurred merchandise provided by Terry Supply Company. The personal guarantee shall remain in force until its revocation is acknowledged in writing. Revocation shall not affect indebtedness incurred prior to receipt of written notice.

Personally Guaranteed by*

Owner, Partner, Corporate Officer/Agent

Title*

Personal Guarantee Statemant*

I hereby personally guarantee full and prompt payment

CONFIDENTIAL CREDIT APPLICATION - INDUSTRIAL

AGREEMENT TO TERMS AND CONDITIONS

PERSONAL GUARANTEE