CREDIT APPLICATION
DATE
/
/
Mail This Application To:
For the purpose of procuring and establishing credit from time to time, with ARC3 GASES and any and all of its subsidiaries and
affiliates, both now and in the future, the undersigned Applicant furnishes the following information and authorizes all
references to release information directly to ARC3 GASES.
INDIVIDUALS/PROPRIETORSHIP
LIMITED LIABILITY COMPANY
PARTNERSHIP
CORPORATION
Years in
Business
Print or Type Individual Name/Corporate Name
Social Security Number
Trade Name If Any
Federal I. D. Number
Mailing Address
Phone Number
Street Address
Fax Number
Complete
this if an:
Individual
or
Proprietorship
Complete
this if a:
Corporation,
LLC
or
Partnership
Previous Home Address
Years at Current Address
Employer
Business Address
Business Phone
Owner, Partner, Corporate Officer
Home Address
Home Phone
Owner, Partner, Corporate Officer
Home Address
Home Phone
Owner, Partner, Corporate Officer
Home Address
Home Phone
Phone Number
Website
Accounts Payable Contact
Email Address
Fax Number
PRINCIPAL SUPPLIERS/CREDIT REFERENCES (List three)
Phone #
Address
Name
Fax #
Phone #
Address
Name
Fax #
Phone #
Address
Name
Fax #
BANK REFERENCE
Address
Name
Is your company tax exempt?
Yes
No
Does your company require purchase orders?
Phone #
If yes, tax exemption certificate must be on file.
Yes
No
Job Numbers?
Yes
No
The undersigned has given the above information for the purpose of obtaining credit for goods and services to be rendered and represents that said
information is accurate and complete. The undersigned understands ARC3 GASES’ terms are net 30 days. The undersigned agrees to pay for all goods
and services provided within 30 days from date of billing. The undersigned understands that ARC3 GASES will add a service charge of 1 1/2% per month
(18% per annum) for any past due balances. If the account is turned over for collection, the undersigned agrees to pay all costs of collection, including
attorney’s fees of 25% and court costs. The undersigned hereby further agrees that he/she, both individually and on behalf of the company, and to the
extent the law allows, waives all rights to object to the venue chosen by ARC3 GASES in any court with jurisdiction to hear cases brought to collect any
past due sums.
Authorized Signature
Title
Date
PERSONAL GUARANTY
(Must be completed on all corporate accounts with less than one year of history.)
For value received and to induce ARC3 GASES, ETC to extend credit to the Customer(s) shown on the reverse side hereof, the Guarantor (even if more than
one) hereby warrants and unconditionally guarantees to ARC3 GASES the full and prompt payment when due (including any accelerated or extended
maturity) of all indebtedness, obligations and liabilities of Customer to ARC3 GASES, including finance charges applicable thereto, now existing or
hereafter created or arising, even if such indebtedness is in excess of the applied for, or established credit line. Guarantor further agrees to pay all
expenses, including expense of court costs and attorney's fees paid or incurred by ARC3 GASES in endeavoring to collect such indebtedness of any part
thereof or in enforcing the Guaranty. The benefit of any homestead or other exemptions are hereby waived by the Guarantor.
The Guaranty shall be enforceable before or after proceeding against Customer, or simultaneously therewith, and without resort to any security.
Any changes to the name, location, personnel, composition, form of organization, or financial structure of Purchaser, Guarantor, or Seller shall not serve to
release Guarantor from its liability to Seller.
This Guaranty shall continue in force until notice in writing of termination sent by registered or certified mail, return receipt requested, is received by ARC3
GASES, Attention: Credit Manager. This notice is to specify the date on which the Guaranty is to be terminated, said date not to be less than seven (7) days
after the described notice is received and shall not affect transactions with Customer entered into prior to the termination date.
This Guaranty is enforceable against the undersigned Guarantors whether or not the signatures are witnessed.
Witness
Date
Guarantor Signature
Social Security Number
Witness
Date
Guarantor Signature
Social Security Number
BUILDING / PROPERTY OWNER
NAME:
ADDRESS:
PHONE #:
CELL #: