Credit Application Form

GENERAL INFORMATION

Legal Name of Business *

Trade Name of Business *

Bill to Address *

City *

State *

Zip *

County

Ship to Address *

City *

State *

Zip *

County

Phone Number *

Fax Number

Accounts Payable Contact *

Accounts Payable Email *

Email address for delivery of invoices/statements *

* Invoices and statements are only sent electronically. Please provide a designated email account.

PROPRIETOR, PARTNERS OR CORPORATE OFFICERS

(Please provide alternate address where we can reach you)

Name *

Title *

Address *

City *

State *

Zip *

Email *

Social Security #

* By signing this credit application, I authorize the person(s) listed on this credit application to carry out security related duties for the company. Social security number required in order to carry out security-related duties for the company.

DESCRIPTION OF BUSINESS

Business Type *

Corporation

Partnership

Proprietorship

Federal ID # *

Incorporation Date

State *

If Subsidiary, Name of Parent Company

Sales Tax Exempt

Yes

BANKING INFORMATION (optional)

Bank Name

Officer

Phone

Fax

Address

City

State

Zip

Checking Account #

Average Monthly Balance

Loan Account #

Balance

TRADE REFERENCES (optional)

REFERENCE #1

Company Name

Account #

Contact Name

Phone

Address

City

State

Zip

REFERENCE #2

Company Name

Account #

Contact Name

Phone

Address

City

State

Zip

REFERENCE #3

Company Name

Account #

Contact Name

Phone

Address

City

State

Zip

CREDIT INFORMATION (optional)

Credit Line Requested $

Financial Statement Enclosed (Required if credit line requested is more than $15,000)

Yes

Listed in Dub & Bradstreet?

Yes

If yes, please list Dub & Bradstreet #

Type of Business

Restaurant

General Contractor

Hospital

Hotel/Motel

Food Service Management

Property Management

Nursing Home

Church

Other

Bld/Facility (optional)

Facility Ownership

Owned

Leased

Rented

Mortgage holder/Landlord (Name)

Permission is hereby granted to obtain credit information from listed credit references including my bank. All financial information submitted in support of this new account and credit application is true and complete in all respects. My account is subject to a late charge of 1.5% per month (18% annual) on all past due invoices. Furthermore, I understand that my account may be turned off if my account is past due and any collection fees (including attorney fees) incurred by MPRS, which the parties hereby fix at 33 1/3% of any balance due plus court costs, will be borne by my account. By signing this credit application, I certify that I am authorized to make this request on behalf of the company and it is agreed that all purchases will be paid in accordance with the terms and conditions.

I assume personal and individual responsibility and liability, as well as guarantee payment of all charges due and payable to MPRS by the company listed here-in. I hereby consent and autorize the use of my consumer credit report in the credit evaluation proccess.

Type or print name and title of owner, partner, or authorized person of purchaser *

Signature:

* is a required field. We will not sell or distribute your information to third parties.