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5722 Bingle Rd Ste # B
Houston TX, 77092
Tel: 713-337-7330
Fax:713-337-7336
Account Executive
 
DATE :  
BUSINESS NAME :  
Billing Address :    City :    Zip :    
Shipping Address :    City :    Zip :    
Telephone No :    Fax No :    Type of Business :    
Years in Business :   Are you Tax Exempt? (If YES, please attach certificate) 
Account Payable Contact    Phone No :    Fax :    
Payment Terms (*Credit Card)    Type   Exp   C.O.D.  Net Term 10 Days  
We Expect our monthly purchases to be :  $
If Credit Card terms are accepted you will receive additional 2 % discount on your invoice. Your invoices will be charged same day.
If Credit card terms are accepted you do not need to fill out business references.
BUSINESS REFERENCES: (Trade, Bank, Personal charge accounts & Credit Cards are NOT Acceptable)
Business Name Complete Address Telephone #
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Terms of Service: I/we understand that the information furnished you on this page is for the purpose of obtaining credit from you firm. That I am/we are authorized in my/our capacity. To bind my/our firm accordingly. That all accounts or monies due shall be due 7 payable at your place of business. That all pass due accounts, notes or judgments shall bear interest paid at the rate of 1.5% per month of unpaid balances. All accounts are net 30 days a service charge of 1.5% per month (18% per annum) is added to all past due;
Authorized Signature (By Applicant)   Print Name and Title
 
 
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