Credit Application

PURCHASER'S CREDIT 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:_____________________

(PRINT FORM and CREDIT TERMS - FILL OUT & SIGN BOTH - MAIL OR FAX TO CREDIT DEPARTMENT)

LEGAL NAME____________________________________________________________________________________________ PHONE(_____)____________-_____________________________FAX (_____)__________-_____________________________
DBA / TRADE NAME_______________________________________________________________________________________
SHIP TO ADDRESS _______________________________________________________________________________________ CITY ______________________________________________________STATE ______________ZIP CODE _________________
MAILING ADDRESS _______________________________________________________________________________________ CITY ______________________________________________________STATE ______________ZIP CODE _________________
KIND OF BUSINESS_______________________________________________________________________________________
TYPE OF ORGANIZATION INDIVIDUAL (___ ) PARTNERSHIP (___ ) CORPORATION (___ ) DATE STARTED UNDER PRESENT MANAGEMENT________________________________________________________________
FEDERAL ID #_____________________________________________DUNS #_________________________________________ CONTRACTORS LICENSE #__________________________________ CLASS__________________________________________

LIST ALL OFFICERS / PARTNERS / OWNERS / SSN IF SOLE PROPRIETORSHIP

NAME_________________________________________TITLE________________________________SSN___________________

NAME_________________________________________TITLE________________________________SSN___________________

NAME_________________________________________TITLE________________________________SSN___________________

ACCOUNTS PAYABLE CONTACT_______________________________________________________________________________
PHONE(_____)____________-_____________________________

BANK_________________________________________ADDRESS___________________________________________________
CITY _______________________________________________________STATE ______________ZIP CODE __________________

PHONE(_____)____________-_____________________________CHECKING ACCOUNT #_______________________________
CONTACT NAME______________________________________ FAX (_____)____________-____________________________

TRADE REFERENCES (Minimum of Four)

NAME________________________________________________ ACCOUNT #_________________________________________

PHONE(______)____________-____________________________FAX (_____)__________-______________________________

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, WHICH ARE PRINTED BELOW. 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 FOR THE PURPOSE OF GRANTING AN OPEN ACCOUNT.
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 _____________________________________________
Form M-106 Revised 3/99

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, WHICH ARE PRINTED BELOW. 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 FOR THE PURPOSE OF GRANTING AN OPEN ACCOUNT.

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 _____________________________________________

Form M-106 Revised 3/99

Click on one of the following to:
Read and Print Credit Terms and Conditions Return to Products and Services