Heritage Galerie - Credit Application

Credit Application


Applicant/Principal Account Debtor
Business Name	*
Business Address	*
Address 2
City	*
State
Zip Code	*

Tax ID #	*
Business License #	*
Sales and Use Tax #	*
Principal Contact	*
Secondary Contact	*
Business Phone	*
Business Fax
Home Phone
Cell Phone

Bank Account #	*
Name of Bank	*
Bank Contact	*
Bank Phone	*

This business is one of the following:
Corporation
Sole Proprietorship
Partnership
This business has been in operation under the present name and ownership for:
Years	*
Months

We require all initial new account orders to be paid with a credit card. We accept AmEx,VISA, MasterCard, and Discover.
After initial order payment terms will be Net 30 based on credit approval.
If you do not qualify for Net 30 terms, your orders will have to be paid with a credit card.
All accounts over 30 days will incur a 1.5% penalty for past due balances.

In order for us to process your business checks please provide us with the following information for the
individuals who are authorized to sign checks. In addition, we need you to complete the reference section of this application

Reference 1
Name	*
Title
Address	*
City	*
State
Zip Code	*
Driver's License #	*

Reference 2
Name	*
Title
Address	*
City	*
State
Zip Code	*
Driver's License #	*

Reference 3
Name	*
Title
Address	*
City	*
State
Zip Code	*
Driver's License #	*

Please provide three (3) sources that currently accept your business checks and/or have extended credit terms to your business.

Company 1
Company Name	*
Account #	*
Address	*
City	*
State
Zip Code	*
Phone	*

Company 2
Company Name	*
Account #	*
Address	*
City	*
State
Zip Code	*
Phone	*

Company 3
Company Name	*
Account #	*
Address	*
City	*
State
Zip Code	*
Phone	*

I/we certify that the above and attached information is true and is furnished for the sole purchase of establishing an account to purchase from Heritage Inc..
If credit is extended, I/we agree to make payment on or before the date due stated on the invoice.
I/we understand that any past due invoices may suspend credit sales and a 1.5% service charge/interest will be added to the amount past due.
I/we agree to pay attorney fees and court costs of collecting or attempting to collect or secure any and all debts which I/we owe to Heritage Inc. for goods sold.
Name of Account Debtor	*
Name of Person Signing	*
Title of Person Signing	*
Date	*