ESI: Apply for credit

Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-Mail:
Years established:
We operate a business that does...
Do you have any type of plans?	Individual Co-Partnership Limited Partnership Incorporated under the state of
We expect our monthly credit requirements from you to be about	$
The principal owners or stockholders or officers are:
Name:
Title:
Home Address with Zip:
Home phone#:
SS#:
PLEASE LIST FIVE TRADE REFERENCES, TWO BANK REFERENCES AND ALL ACCOUNT NUMBERS:
BANK REFERENCES:
#1) Name:
#1) Mailing Address:
#1) Phone#:
#1) Account#:

#2) Name:
#2) Mailing Address:
#2) Phone#:
#2) Account#:
TRADE CREDIT REFERENCES
#1) Name:
#1) Mailing Address:
#1) Phone#:
#1) Account#:

#2) Name:
#2) Mailing Address:
#2) Phone#:
#2) Account#:

#3) Name:
#3) Mailing Address:
#3) Phone#:
#3) Account#:

#4) Name:
#4) Mailing Address:
#4) Phone#:
#4) Account#:

#5) Name:
#5) Mailing Address:
#5) Phone#:
#5) Account#:

Terms of sale are net cash thirty (30) days from date of invoice, subject to cash discount ifany, as shown on the face of the invoice for payment by the tenth day of the following month,and subject to a service charge if delinquent. A service charge of one and one half percent (1-1/2%) per month will be applied to all accounts which are delinquent forty-five (45) days past the discount date shown on the face of the invoice. In consideration of the credit extended hereby, including all future advances, and to secure payment thereof, applicant hereby grants to Electrical Supplies, Inc., its agents or assigns, a security interest in all presently owned and/or after acquired supplies and materials being purchased wherever located and including proceeds thereof. And default upon the terms of this credit application or other agreements with Electrical Supplies, Inc. shall constitute a default in the security agreement. Should customer default, Electrical Supplies, Inc. may take possesion of the collateral and may pursue all other remedies referred to in Article IX of the Uniform Commercial Code. Remedies are cumulative. Furthermore, should it become necessary to place this account with an attorney for collection, suit or other legal action, I/we hereby agree to pay all costs of such collection, suit other legal action, including a reasonable attorney's fee at both the Trial and Appellate levels. Venue shall lie in either Dade or Broward County, Florida, at the discretion of Electrical Supplies, Inc. Pressing "Submit" below indicates my permission for Electrical Supplies, Inc. to obtain credit information from the sources I have referenced , including any external credit reporting source. The undersigned agrees that the information contained above is true and correct. The undersigned further agrees that any change in ownership or officers or form that the business has been operated as shall be made known to Electrical Supplies, Inc. in writing by certified mail to Electrical Supplies, Inc. 13395 NW 107th Avenue, Miami, FL 33018.