Independent Pipe Individual Credit Application

Company Name:
Street Address:
City:	State:	Zip Code:
Telephone No:	Fax No:
Date Business Started:	Incorporated Under Laws of the State of:

Type of Business:

PLBG:

HTG:

REFRIG:

A/C:

Other:

Type of Account:

Individual Account: Partnership Account:

(If partnership, each partner must complete a seperate individual application.)

Please state your full and complete legal name:

First Name: Middle Name: Last Name:

Business Address: Telephone No:

Residence Address: Telephone No:

Social Security No: (No spaces or dashes, just numbers) Spouse's Name:

Number of dependents:

Name and Address of Nearest Relative or Friend (Not Living With You):

Do you own your own residence?: Yes No
Please indicate your monthly mortgage or rent payment$:

CREDIT REFERENCES:

For each case please indicate whether the account is in your name, your spouse's or another person, a joint account or in the name of the applicant business.

Name of Bank	Address, City	Account#	In whose name
1
2
3

Trade References:

Company Name & Address: Tel Number:

Other Credit References:

Check One: Sales Tax No Sales Tax

Are purchase orders are required?: Yes No

Terms and Conditions

I/We authorized the person or firm to whom this application is made to investigate the references listed pertaining to my/our credit responsibility.  Furthermore, I agree to the terms of sale and returns policy of your company and all reasonable costs, collections fees, attorneys' fees and expenses incurred by me in the event of failure of applicant to pay all obligations and indebtedness when due.  Our terms include 1 - 1/2% Service Charge per month (18% per annum) on the unpaid balance after 30 days of the Statement date.

----------------------Personal Guaranty----------------------
In consideration of the extending of the credit to the above company at my request, I hereby guarantee to Independent Pipe & Supply Corp. the prompt payment, when due, of every claim and debt of the above company to Independent Pipe & Supply Corp.  This guarantee is given by accepting these terms in order to induce Independent Pipe & Supply Corp. to extend credit to the above named company.  I hereby agree to bind myself to pay Independent Pipe & Supply Corp. on demand any sum, which may be or become due to Independent Pipe & Supply Corp. by the company whenever the company shall fail to pay the same.  At its election and in its sole discretion, Independent Pipe & Supply Corp. may demand and collect payment of overdue amounts, costs and Attorneys’ fees on the above account from either the above company or the individual who submits this form.  It is agreed suit may be brought in the Commonwealth of Massachusetts.   This individual Guaranty is continuing and may only be revoked prospectively.  Any such revocation to be effective must be signed and in writing.  NOTICE: All notices and agreements shall be in writing and the parties can use the U.S. mails, any delivery service, which obtains and will furnish a signature evidencing delivery to the addressee or a Fax transmission, which provides sender with a record of such transmission being received.

CLICKING BELOW CONSTITUTES ACCEPTANCE OF
THE TERMS AND CONDITIONS ABOVE!