Corporation Partnership Proprietorship

COMPANY

YEAR STARTED # EMPLOYEES

NATURE OF BUSINESS

ADDRESS

CITY

STATE             ZIP

TELEPHONE          FAX

OWNER/OFFICER (NAME/TITLE)

ACCOUNTS PAYABLE

CONTACT NAME

CONTACT EMAIL

SUPPLIER REFERENCES

NAME

COMPANY

STREET ADDRESS

 CITY STATE    ZIP

 NAME 

COMPANY

STREET ADDRESS

CITY  STATE    ZIP

BANK REFERENCE

NAME

BANK

STREET ADDRESS

CITY  STATE ZIP

PHONE       FAX

CONTACT 

ACCOUNT NUMBER

The undersigned representative understands and agrees that should credit be extended to the above listed company, or to the individual representative, payments are to be made in accordance with terms, as set forth on Philadelphia Carbide's invoice. Furthermore, accounts are considered PAST DUE AT 30 DAYS (or over) AND ARE SUBJECT TO SERVICE CHARGES of 1.5% PER MONTH (or 18% per annum). It is further understood and agreed that in the event it becomes necessary for Philadelphia Carbide to engage in services of any agency or attorney to collect payment for merchandise sold, the purchaser will pay all collection costs, including but not limited to, reasonable legal fees and court costs incurred by the seller in both pre-judgment and post-judgment collection actions.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE PARAGRAPH and certify the accuracy of the information listed on this application.

NAME   TITLE

DATE