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Arizona AFO™ , Inc. - Application
for Credit |
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| Date: | Business Name | |
| D/B/A: | Owned By: | |
| Business Address | ||
| City | State | Zip |
| Telephone # | Fax # | Email Address |
| Contact Person | Federal Tax ID # | Resale # |
| Company
Information: (circle one) Corporation Partnership Proprietorship Franchise |
Date Company Established: | |
| Type of Business | ||
| Banking Information | ||
| Bank | Address: | |
| City: | State: | Zip |
| Checking Account # | Contact: | |
| Tel: | Fax: | |
| Trade References | Please Note: These companies no longer furnish credit information: CAMP, OTTO BOCK, JUZO. | |
| Company | Tel: | Acct. # |
| Address: | Fax: | Contact: |
| Company | Tel: | Acct.# |
| Address: | Fax: | Contact: |
| Company | Tel: | Acct. # |
| Address: | Fax: | Contact: |
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Acceptance of Terms |
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Upon approval of this application, your business account will be opened for
your convenience. All bills are due in our office within 30 days of the
date of each invoice. A late charge will be added to all amounts not paid
within 30 days from date of invoice at the rate of one and one-half
percent (1.5%) per month or 18 percent per annum. If failure to pay according to the terms of the agreement causes this account to be assigned or referred to an attorney for collection, buyer agrees to pay seller's reasonable collection and/or attorney's fees and all court costs. The undersigned hereby certifies that he or she is duly authorized to sign this application on behalf of applicant/buyer, that the information given in this application is true and correct to the best of his or her knowledge and that the applicant/buyer hereby agrees to the foregoing terms and conditions. |
| For the purpose of obtaining merchandise
from Arizona AFO™, Inc. on credit, Retailer provides the
above information and warrants to Arizona AFO™, Inc. that the information is complete,
true and accurately reflects the present financial condition of Retailer. The above company hereby grants permission to Arizona AFO™, Inc. to verify the above information, and further agrees to all purchase terms and conditions on this application. By my signature below, I confirm that I am duly authorized to bind the company and, that all the information in this application is complete and correct, and the company has the necessary financial ability and willingness to pay for these goods hereafter purchased from Arizona AFO™, Inc., promptly and in accordance with all these terms and conditions. Date:____________________________ Signature:_____________________________________________________________ |