7777 Winn Road
Spring Grove, IL60061
815.675.7410 (Fax)
BILLING ADDRESS:PERSON TO CONTACT REGARDING PAYMENT:
______
Customer NameName
______
Street AddressTitle
______
City, State, Zip CodeAccounts Payable Phone Number Fax Number
______
Telephone NumberEmail Address
______
Years in Business Type of BusinessInitial Order Amount $ Est. Annual Purchases $
BANK REFERENCE:
______Bank Contact: ______
Name on Account(if different)
Phone/Fax No.:______
______
Bank NameAccount Number: ______
______
Address/City/StateType of Acct.: ______
TRADE REFERENCES:
1. Name______2. Name ______
Address______Address ______
Phone/Fax______Phone/Fax ______
Contact______Contact ______
3. Name______4. Name ______
Address______Address ______
Phone/Fax______Phone/Fax ______
Contact______Contact ______
INTERMATIC INC. TERMS AND CONDITIONS:
The undersigned certifies that the information given is correct and accurate as of the date of this application. Credit Applications transmitted electronically will assume electronic signature. All accounts and monies due to Intermatic Inc. shall be due and payable in good funds at Intermatic Inc.’s place of business, and the terms granted are N30 unless otherwise agreed upon in writing. All payments are due and payable thirty (30) days from the date of invoice unless otherwise agreed upon in writing. All amounts past due may incur interest at the rate of 1.5% per month or the highest rate permitted by law, whichever is more. In the event of default and/or referral to a Third Party Collection Agency or Attorney, Customer agrees to pay all costs and fees of such services. Furthermore, Customer understands and agrees to any Conditions of Sale established by Intermatic Inc. Customer further understands that failure to pay invoices within approved payment terms may result in further shipments being suspended and its account placed on credit hold. All credit to be obtained hereunder shall be for business purposes only, and not for family, personal or household purposes.
TO ALL BANK, TRADE REFERENCES AND CREDIT REPORTING BUREAUS:
Customer unconditionally authorizes the above-described bank and trade references (and any other credit reporting company), to discuss with Intermatic Inc. any credit or financial history information regarding Customer without further consent of or liability to Customer. The application will serve as our request and your authorization to release any information concerning the Customer. All information obtained by Intermatic Inc. is held strictly confidential.
SALES TAX EXEMPT CLAIMS:
In order to be in compliance with state laws and honor Company’s request, if any, for any sales tax exemption status, it is required that Intermatic Inc. has on file from Company a properly completed signed “Sales Tax Exemption Certificate” for each state to which Intermatic Inc. ships product. A copy of a state registration certificate or business license is notvalid. If Intermatic Inc. does not have on file from Company the proper documentation for a shipment, the order will be billed to Company with the appropriate sales tax charge. If at a later date, due to an audit by a taxing authority, it is determined that your certification for exemption from sales tax is not valid; you will be billed for any additional sales tax, interest and penalties that Intermatic Inc. pays on your behalf.
Please attach a copy of all Sales Tax Exemption Certificates applicable in regard to your account with Intermatic Inc.
______
Customer SignatureName and Title PrintedDate
Rev 03/01/07