Credit Applications

CREDIT APPLICATION

Fax to: 800-822-1524(Randolph, Hale and Meredith, Inc.)

This form can be printed as a blank and filled out, or can be filled out and then printed.

A signature is necessary at the bottom of the page. After this, please fax to one of the above numbers.

Company name:

Phone #:

Fax#:

E-mail:

Billing address:

City:

State: Zip:

Shipping address:

City:

State:Zip:

Corporation: Yes No President:

If a division or subsidiary, name of parent corp.:

Proprietorship:Yes No

List owner:

Years in business: Annual sales:

Are purchase order #'s required?Yes No

Amount of credit requested:

Type of business:

General Mgr.:

Accts Payable Mgr.:

List names authorized to purchase:

TRADE REFERENCES

Name:

Phone:

Fax:

Address:

City:

State: Zip:

Name:

Phone:

Fax:

Address:

City:

State: Zip:

BANK

Name:

Phone:

Fax:

Address:

City:

State: Zip:

Account#:

Authorization for Bank Release:Signature:_________________________________

Resale Tax# If applies, send copy of certificate.

Randolph, Hale and Meredith, Inc. has permission to check with anyone listed above for information regarding our company's credit history.

I certify that the information given above is true and correct to the best of my knowledge. I agree to abide by your credit terms, and further agree that a service charge of 2 percent per month may be added to this account should it become past due. We further agree that all cost, should it become necessary, for collection of this account will be paid by this company.

Officer's Signature:_____________________________________________Date____/____/____