PWC - Potter Webster

APPLICATION FOR CREDIT

APPLICATION TYPE^*

COD Account Business Account

ALL SECTIONS WITH A RED ASTERISK^* MUST BE COMPLETED BEFORE YOUR APPLICATION CAN BE PROCESSED.

Company Name^*

Date^*

BILLING ADDRESS

Address^*

City^*

State/Province^*

ZIP^*

SHIPPING ADDRESS

Checkbox Same Address

Same as Billing Address

Address

City

State/Province

ZIP

Office Ph #^*

Shop Ph #

Office email^*

Fax #

Description of Business^*

Owner(s) / President Name^*

A/P Contact^*

Shop Contact

Purchase orders Required^*

Yes No

# of employees^*

# years in business^*

Federal Tax ID^*

Motor Carrier #

WA tax exempt #

Credit amount requested^*

CREDIT REFERENCES

(List three Trade References - No Financial Institutions or Revolving Accounts)

Name^*

City^*

State^*

Fax

Phone^*

Name^*

City^*

State^*

Fax

Phone^*

Name^*

City^*

State^*

Fax

Phone^*

POTTER WEBSTER COMPANY’S CREDIT TERMS AND AGREEMENT

Credit terms are Net 30 Days. Payment is due 30th days after purchase is made. A statement listing all unpaid invoices will be mailed or emailed to you each month. Accounts which become past due will be put on COD or credit hold until paid in full, and a service charge of 2% per month (Annual percentage rate of 24%) will be assessed on the past due balance. Your account will be assigned a maximum credit limit, subject to review at any time. When this credit limit has been reached, your account will be on COD or credit hold until payment is received to reduce the balance of the account below the credit limit.

The undersigned hereby agrees to the terms stated above and authorizes the listed bank and credit references to release to Potter Webster Company any information necessary to assist in establishing a credit account. All information received by Potter Webster Company will remain strictly confidential. The undersigned agrees to all terms and conditions of payment and agrees that employees may have the authority to purchase on behalf of the company unless written restriction is provided to Potter Webster Co. In the event of collection, the undersigned agrees to pay all collection costs.

Company Name^*

Name^*

Title^*

Authorized signature^*

(Digital signature constitutes a contract agreement)

Date^*

PERSONAL GUARANTEE

The party identified below agrees to be personally obligated to pay all debts incurred under the credit agreement signed above. They also give permission for Potter Webster Company to run their personal credit information for the purposes of determining credit worthiness.

Name

SS #

Address

Signature

(Digital signature constitutes a contract agreement)

Date

PORTLAND, OR (Corporate)

41 NE Walker St., Portland, OR 97211
(503) 283-4792

EUGENE, OR

86175 Franklin Blvd., Eugene, OR 97405
(541) 928-3331

LONGVIEW, WA

40 International Way, Longview, WA 98632
(360) 577-9632

APPLICATION FOR CREDIT

ALL SECTIONS WITH A RED ASTERISK^* MUST BE COMPLETED BEFORE YOUR APPLICATION CAN BE PROCESSED.

CREDIT REFERENCES

(List three Trade References - No Financial Institutions or Revolving Accounts)

POTTER WEBSTER COMPANY’S CREDIT TERMS AND AGREEMENT

PERSONAL GUARANTEE

PORTLAND, OR (Corporate)

EUGENE, OR

LONGVIEW, WA

Please pick any one color

You can compare only 3 products

APPLICATION FOR CREDIT

ALL SECTIONS WITH A RED ASTERISK* MUST BE COMPLETED BEFORE YOUR APPLICATION CAN BE PROCESSED.

CREDIT REFERENCES

(List three Trade References - No Financial Institutions or Revolving Accounts)

POTTER WEBSTER COMPANY’S CREDIT TERMS AND AGREEMENT

PERSONAL GUARANTEE

PORTLAND, OR (Corporate)

EUGENE, OR

LONGVIEW, WA

Please pick any one color

You can compare only 3 products

ALL SECTIONS WITH A RED ASTERISK^* MUST BE COMPLETED BEFORE YOUR APPLICATION CAN BE PROCESSED.