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PURCHASER'S ACCOUNT APPLICATION |
SHIELDS,
HARPER & CO.
AN EMPOYEE OWNED COMPANY P.O. BOX 3066 OAKLAND, CA. 94609 PHONE: (510) 653-9119 FAX: (510) 658-8448 |
OFFICE USE ONLY : Territory:___________________ Class:____________________ Credit Limit:________________ Approved By:_______________ Date:_____________________ |
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LEGAL NAME____________________________________________________________________________________________ |
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DBA / TRADE NAME_______________________________________________________________________________________ |
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SHIP TO ADDRESS _______________________________________________________________________________________ |
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MAILING ADDRESS _______________________________________________________________________________________ |
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KIND OF BUSINESS_______________________________________________________________________________________ |
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TYPE OF
ORGANIZATION
INDIVIDUAL (___ )
PARTNERSHIP (___ ) CORPORATION
(___ ) |
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FEDERAL ID #_____________________________________________DUNS
#_________________________________________ |
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LIST ALL OFFICERS / PARTNERS / OWNERS / SSN IF SOLE PROPRIETORSHIP |
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NAME_________________________________________TITLE________________________________SSN___________________ |
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ACCOUNTS PAYABLE CONTACT_______________________________________________________________________________
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BANK_________________________________________ADDRESS___________________________________________________ |
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TRADE REFERENCES (Minimum of Four) |
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NAME________________________________________________
ACCOUNT #_________________________________________ |
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NAME________________________________________________
ACCOUNT #_________________________________________ |
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NAME________________________________________________
ACCOUNT #_________________________________________ |
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NAME________________________________________________
ACCOUNT #_________________________________________ |
| PLEASE ATTACH :
CURRENT FINANCIAL STATEMENT
/ RESALE CERTIFICATE (If applicable) I HAVE READ AND AGREE TO THE TERMS AND CONDITIONS OF ANY SALES MADE BY SHIELDS, HARPER & CO. INCLUDING LIMITATIONS OF WARRANTIES, I HEREBY STATE THAT THE INFORMATION GIVEN IS TRUE TO THE BEST OF MY KNOWLEDGE AND I AUTHORIZE SHIELDS, HARPER & CO. TO CHECK THE REFERENCES LISTED. |
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BE
SURE TO PRINT AND SIGN BOTH THIS FORM AND THE CREDIT TERMS AND CONDITIONS.
BOTH FORMS MUST BE SIGNED AND RECEIVED BEFORE WE CAN PROCESS YOUR APPLICATION.
PRINT NAME___________________________________________TITLE_____________________________________________ SIGNATURE ___________________________________________ DATE _____________________________________________ |
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| Form M-106 Revised 3/99 |