PWC - Potter Webster

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APPLICATION FOR CREDIT

ALL SECTIONS MUST BE COMPLETED BEFORE YOUR APPLICATION CAN BE PROCESSED

nombre de empresa^*

Date^*

Dirección Facturación

Address^*

City^*

State/Province^*

ZIP^*

Dirección de envío

Address^*

City^*

State/Provincee^*

ZIP^*

Office ph #^*

shop ph #^*

Office email ^*

Fax # ^*

Description of Business ^*

Owner (s)/ President name ^*

A/P Contact ^*

Shop Contact ^*

Purchase orders Required^*

Yes

Authorized Persons ^*

# years in business ^*

# of employees ^*

Motor Carrier # ^*

WA tax exempt # ^*

Credit amount requested ^*

COD Only Account (please check) ^*

Yes

CREDIT REFERENCES

(LIST THREE TRADE REFERENCES - NO FINANCIAL INSTITUTIONS OR REVOLVING ACCOUNTS)

Name ^*

City ^*

State ^*

Fax ^*

Phone ^*

Name ^*

City ^*

State ^*

Fax^*

Phone ^*

Name ^*

City ^*

State ^*

Fax ^*

Phone ^*

POTTER WEBSTER COMPANY’S CREDIT TERMS AND AGREEMENT

Credit terms are Net 30 Days. Payment is due 30th days after purchase is made. A statement listing all unpaid invoices will be mailed or emailed to you each month. Accounts which become past due will be put on COD or credit hold until paid in full, and a service charge of 2% per month (Annual percentage rate of 24%) will be assessed on the past due balance. Your account will be assigned a maximum credit limit, subject to review at any time. When this credit limit has been reached, your account will be on COD or credit hold until payment is received to reduce the balance of the account below the credit limit.

The undersigned hereby agrees to the terms stated above and authorizes the listed bank and credit references to release to Potter Webster Company any information necessary to assist in establishing a credit account. All information received by Potter Webster Company will remain strictly confidential. The undersigned agrees to all terms and conditions of payment and agrees that employees may have the authority to purchase on behalf of the company unless written restriction is provided to Potter Webster Co. In the event of collection, the undersigned agrees to pay all collection costs.

nombre de empresa ^*

Name ^*

Title ^*

Authorized signature ^*

(Authorized signature Digital signature constitutes contract agreement)

Date ^*

Personal Guarantee

The party identified below agrees to be personally obligated to pay all debts incurred under the credit agreement signed above. They also give permission for Potter Webster Company to run their personal credit information for the purposes of determining credit worthiness.

Name ^*

SS # ^*

Address ^*

Signature ^*

(Digital signature constitutes a contract agreement)

Date ^*

MAIN BRANCH

41 NE Walker St., Portland, OR 97211
(503) 283-4792
(503) 735-3305 Fax

EUGENE, OR

86175 Franklin Blvd., Eugene, OR 97211
(541) 928-3331
(541) 967-8693 Fax

LONGVIEW, WA

40 International Way, Longview, WA 98632
(360) 577-9632
(360) 577-0836 Fax

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