P.O.Box 1408 • 8631 Hayden Place • Culver City, CA 90232-1408 • Phone (800) 622-4456 • Fax (310) 841-0647

CUSTOMER CREDIT APPLICATION AND PERMANENT FILE UPDATE


* Indicates a required field

Customer Name: *
DBA (If Applicable):
Billing Address: *
Shipping Address:
(If Different) 
Phone: * Fax: *
E-Mail: * Resale #: 1 *
Company Officers:
Name: *

Name:  

Title: *

Title:  

Terms Requested:            Net 10 *         C.I.A. *  
Would you like to pay by credit card? 2
Your Security is Guaranteed! All systems are in place to ensure that your information remains safe and secure.

First order only: *   All Orders: *  
Name as it appears on card: * Card Type: *
Card #: * Exp. Date: * V-Code: *
Bank Name: *
Bank Contact: *
Account Number(s): *
Bank Phone: * Bank Fax: *
Manufacturer: * Dealer Account #: *
Contact: * Phone: *
  Fax: 3 *
Manufacturer: * Dealer Account #: *
Contact: * Phone: *
  Fax: *
Manufacturer: * Dealer Account #: *
Contact: * Phone: *
  Fax: *
OK to partial: * Ship collect?: * Carrier: *
  Minimum Shipment Value: *   Special Instructions: *
  Sales Rep: *      Are you interested in ordering online? *       
  Applicant Name: *    Date: 2/22/2012
1 Please note that a valid California resale number is required of all dealers located in, or shipping into California and failure to provide will result in held orders.
2 A 3% transaction fee applies to credit card chargers.
3 Please provide a fax number for all trade references. Failure to provide a valid fax number will result in delays of processing your credit application.
4 By sending this application, you hereby authorize the L.Powell Acquisition Corp. to contact your bank for a reference. Also, if supplied, you authorize the L.Powell Acquisition Corp. to charge the credit card provided for either your initial order or subsequent orders if requested.

I represent that the information provided is true and given to L.Powell Acquisition Corp in an attempt to extend credit to the applicant. My company and I authorize L.Powell Acquisition Corp to make such credit investigation as L.Powell Acquisition Corp sees fit, including contacting trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks and credit reporting agencies to disclose to L.Powell Acquisition Corp any and all information concerning the financial and credit history of my company and myself.


PERSONAL GUARANTEE:  If the credit customer is a corporation, then those sending this application, whether signing as an officer or not, personally guarantee payment for all items purchased on credit by the corporation.

GENERAL TERMS AND CONDITIONS

Invoices are to be paid in full within the credit terms granted. Invoices not paid within these terms will be considered past due. No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.

I have read the terms and conditions stated below and agree to all of these terms and conditions.

  Applicant Name: *   Social security #: *