THE ELECTRIC MOTOR REPAIR COMPANY
9100 Yellow Brick Road, Suite H - Rosedale, MD 21237
(410) 467-8080 - (800) 879-4994 - Fax (410) 467-2512

APPLICATION FOR CREDIT

NAME OF FIRM OR INDIVIDUAL
FEDERAL ID NUMBER PURCHASE ORDER REQUIRED ?
Yes No		 CREDIT CARD PAYMENT
Yes No
DBA
TYPE OF BUSINESS
 YR ESTABLISHED YRS AT PRESENT LOC
ADDRESS
BUYER'S NAME PURCHASE ORDER REQUIRED?
Yes No
CITY STATE ZIP
SHIP TO:
PHONE FAX
ADDRESS
EMAIL ADDRESS ACCTS PAYABLE CONTACT
CITY STATE ZIP
TAX EXEMPT?
Yes No		 TAX EXEMPT #
PHONE FAX
 
THE FOLLOWING MUST BE COMPLETED BY OWNERS, PARTNERS, OR OFFICERS
 
OWNERSHIP: CORPORATION Incorporated in
last 12 months		 PARTNERSHIP PROPRIETOR / Social Security No:
NAME(S) OF PRINCIPAL(S) TITLE HOME ADDRESS CITY STATE ZIP
1.
2.
3.
 
AUTHORIZATION: To induce EMR to extend a line of credit for purchases under credit sales terms as stated on invoices, we authorize you to contact the banks and trade references listed below. We also understand that this information will be held in strict confidence and will be used solely for the consideration of extension of credit.
Signature Title Date
 
BANK REFERENCE:
BANK NAME ADDRESS CITY STATE ZIP
PHONE FAX CONTACT ACCOUNT NO.
TRADE REFERENCES: (Suppliers Only - 4 references are required to process your credit application)
BUSINESS NAME CITY STATE ACCOUNT NO. PHONE NO. FAX NO.
1.
2.
3.
4.
CREDIT TERMS AND CONDITIONS:
All invoices are due 30 days from invoice date with no discount. This credit application is valid for a period not to exceed 2 years from approval date. Credit can be withdrawn at any time for violation of the stated credit terms. Upon failure of applicant to pay any indebtedness to EMR when due, the entire balance may be declared in default and immediately due and payable upon demand. Applicant agrees to pay any and all attorney fees, court costs, collection agency fees, etc. incurred in the collection of said account. Applicant also agrees to pay interest at the rate of 1.5% per month on all past due balances.
 
PERSONAL UNCONDITIONAL GUARANTEE
In consideration for the extension of credit by The Electric Motor Repair Company, the undersigned guarantor individually, jointly, severally and unconditionally guarantees the prompt payment of all sums for which applicant becomes indebted to The Electric Motor Repair Company.
 
Agreed By:
Signature of Applicant/Guarantor Date
Applicant/Guarantor's Printed Name Title
   

 

Fax completed application (with signature) to 410-467-2512