APPLICATIONFOR PLEASE TYPE OR PRINT |
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B.J. Esberner & Assoc, Inc. 5707 West Howard St. Niles, IL 60714 (847)
588 0860 ph (847)
588 1128 fax sales@tooldudes.com |
| We do not accept NET-30 accounts for opening orders under $500. For smaller orders please use major credit card, mail-in a check, money order, or cashier's check. Allow up to 10 business days for check to be processed. |
NAME OF COMPANY _________________________________________ PHONE # _______________
NAME OF PARENT COMPANY _________________________________ FAX # __________________
Street Address__________________________________________________________________________
City, State Zip _______________________________________ Email Address _____________________
KIND OF BUSINESS____________________________________________________________________
DUN & BRADSTREET # ____________________________ EIN _______________________________
Year Established _____________ Year Incorporated ___________ Present Location Since ____________
TYPE OF OWNERSHIP: Corporation _______ Partnership _________ Sole Proprietorship _________
Owner’s Name(s) ________________________________________ SS # __________________________
President ___________________________ SS # ________________ Vise Pres _____________________
Purchasing Agent ___________________________ Accounts Payable ____________________________
HOW DID YOU HEAR OF US? ___________________________________________________
PO # REQUIRED? YES ____ NO ____ WRITTEN PO REQUIRED? YES ____ NO ____
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REFERENCES: (OPEN ACCOUNTS WITH FAX NUMBERS ONLY)
NAME __________________________________ NAME _______________________________________
ADDRESS _______________________________ADDRESS ____________________________________
CITY _________________ ST ___ ZIP ________ CITY _________________ ST ___ ZIP _________
PHONE _________________ FAX ______________ PHONE _______________ FAX _______________
NAME __________________________________ NAME _______________________________________
ADDRESS _______________________________ADDRESS ____________________________________
CITY _________________ ST ___ ZIP _______ CITY _________________ ST ___ ZIP _________
PHONE ________________ FAX _____________ PHONE _________________ FAX _______________
NAME __________________________________ NAME _______________________________________
ADDRESS _______________________________ADDRESS ____________________________________
CITY _________________ ST ___ ZIP ________ CITY _________________ ST ___ ZIP _________
PHONE _________________ FAX ______________ PHONE _______________ FAX _______________
NAME __________________________________ NAME _______________________________________
ADDRESS _______________________________ADDRESS ____________________________________
CITY _________________ ST ___ ZIP _______ CITY _________________ ST ___ ZIP _________
PHONE ________________ FAX _____________ PHONE _________________ FAX _______________
BANK(S) ____________________________________ ACCOUNT # ____________________________
______________________________________ ACCOUNT # ____________________________
| The above information is for purposes of obtaining credit is warranted to be true and accurate. You have my authority to contact any of the above persons or companies to verify my credit experience. I understand that the terms are NET 30 DAYS and I agree to pay a 1-1/2% (APR 18%) Service Charge on all invoices past due. The undersigned also agrees to pay ALL costs of collecting delinquent payments including attorney’s fees. |
Signature ___________________________________________ Title _______________ Date _________
Print Name _________________________________________