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Warehouse

Request Credit Account

Credit Account Application

Billing & Shipping Information

Your Name
Shipping Address
Mailing Address (IF DIFFERENT THAN SHIPPING ADDRESS)

Your Company's Profile

Business Structure 

Company Principals and/or Officers

Principal #1

Name
Address

Principal #2

Address

Were any of the principals in business before?  
Is the buyer currently or has the buyer filed a voluntary or had an involuntary insolvency proceeding filed against them within the last 14 years?  
Are you currently a party to any lawsuit, or are there any outstanding judgements against the buyer? 

About Your Company

Work is conducted from  
Are PO's required? 
Building
Is a job name required? 
Is company sales tax exempt? 
EPA Refrigerant Certified? 

Financial Information

Owned Real Estate

Please provide details on any owned real estate.
ADDRESSVALUETITLED IN NAME OFBALANCE OWEDMORTGAGE COMANY
Are your financial records available for the last two accounting periods? 

References & Major Suppliers

Please provide reference & major supplier information. 
REFERENCE NAMECITY, STATE, ZIPPHONEFAXACCOUNT #

Terms & Conditions

It is agreed the buyer will pay all Invoices within stated terms and agrees to all terms contained in Invoices supplied by seller as maybe amended from time to time. In the event payment is not timely made, the buyer also agrees to pay a time-price differential charge (service charge) of the lesser of2% per month (24% per annum) or the maximum lawful rate on all overdue amounts, and to pay all collection costs incurred by seller in enforcement of the terms and conditions of this agreement, Including court costs, actual reasonable attorney's fees and collection agency fees, within the standards of the industry, but not less than 25% of the unpaid amount of the principal and accumulated service charge all without relief from valuation and appraisement laws. If legal action becomes necessary by either buyer or seller, the buyer agrees that this or any contemporaneous or subsequent agreement will be governed as to validity, interpretation, construction, effect and all other respects by laws of the State of Indiana. Buyer further agrees that In the event legal action becomes necessary by either buyer or seller, Jurisdiction and preferred venue shall remain in Elkhart County, in the State of Indiana. Buyer further agrees that any line of credit desired or approved Is not a limitation of liability, and the undersigned expressly agrees that it will be responsible for valid charges in excess of a line of credit either desired or approved. Having obtained all necessary authority, the undersigned authorizes seller and its agents, attorneys and employees to investigate the credit standing, financial circumstances and responsibility of buyer and all owners, partners, and/or officers listed on the reverse side hereof, and authorizes and Instructs all persons having Information concerning buyer's credit standing, financial circumstances and responsibility to release such Information to seller, Its agents, attorneys or employees. This Includes without limitation, authorization for seller and its agents, attorneys and employees to request, obtain, and use for all purposes which seller deems necessary, a copy of any credit bureau or consumer credit report for the entities/persons listed herein at any time. The buyer further grants to seller a security interest in buyer's equipment, contract rights, inventories, receivables and proceeds of sales as collateral to secure the buyer's performance of all obligations. The buyer hereby appoints any employee, agent, or attorney of seller as buyer's attorney in fact to endorse and file on behalf of buyer any UCC 1 form to perfect or record the security interest. All of the information supplied by buyer is correct to the best of the knowledge of the undersigned, and the buyer understands that all goods or services purchased from seller are subject to all terms and conditions contained in this credit application and agreement and all other terms and conditions contained on any of the seller's invoices.

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Credit Policy of Mid-City Supply Company, INC.

1. To our approved customers, we sell on open account. Our standard terms are Net End of Month Prox.

2. If your account becomes past due, it is subject to being placed on Credit Hold. Should this happen, no orders will be shipped nor will new orders be accepted until the past due balance is paid, or acceptable arrangements are made to clear the past due balance.

3. If your account becomes ninety(90) or more days past due, it is subject to being placed with an outside collection agency or local attorney. Per the Terms and Conditions of the open account, all cost of collection is the responsibility of the debtor.

4. If your account becomes past due, please call us. We will do our best to work with you in resolving any problems you may have in paying your account. Your continued goodwill is important to us.

5. If yoti receive a monthly statement, please review it and notify us if you find a discrepancy. We will make every effort to resolve any discrepancies as quickly as possible.

6. Authorization must be obtained prior to all returns. A packing slip must accompany all returned product.

7. Returns are subject to a restocking fee. Returns are not allowed on special order items.

8. Past due balances are subject to a service charge of 2% per month

9. Your account will be charged sales tax unless a valid state tax exemption certificate is received by Mid­City Supply Company, Inc. To ensure that sales tax is not charged in error, please make sure your certificate is on file prior to any shipments.

I have read the above Credit Policy, and agree to abide by and be bound by the terms of this policy.

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