NEW CUSTOMER INTAKE FORM / CREDIT APPLICATION

SECTION 1: APPLICANT INFORMATION:

Company or Individual *

Full Legal Name of Company or Indvidual *

Operating Name (D/B/A or T/A if different) *

Type of Entity *

Years in Business

IRS Tax # *

SECTION 2: CONTACT INFORMATION:

Mailing Address *

Office Phone

Contact Person First Name *

Contact Person Last Name *

Mobile *

Email *

Invoice Preference *

Delivery Address *

SECTION 3: SALES TAX EXEMPTION INFORMATION:

Purchases qualify as tax exempt. *

Yes

If yes, Check reasoning for tax exemption below:

Sales Tax Exemption/Registration Number

APPLICANT MUST PROVIDE COPY OF STATE TAX EXEMPTION DOCUMENTATION PRIOR TO SHIPMENT Email documentation to [email protected]

SECTION 4: BANK REFERENCE:

Bank Name *

Account Number

Phone Number

Bank Address *

Account Manager

SECTION 5: TRADE REFERENCES (Please Provide Three References):

Reference #1 *

Reference #2

Reference #3

HE Smith Company, Inc. will accrue finance charges at a rate of 2.0% per month (24%APR) on any overdue balance. Any payments returned for insufficient funds will incur a $25.00 fee in addition to any bank fees. I fully understand HE Smith Company’s credit terms and agree to the proper payment in consideration of extended credit. In consideration for the extension of credit to the undersigned, I jointly and personally guarantee to be directly liable for payment of any and all invoices, accounts, and any interest, attorney or collection fees resulting from the account being considered in default. This shall be a continuing personal guarantee which shall continue in force and effect until the account is paid in full and shall not be affected by any extension of time or modifications to this agreement with or without my consent.

I acknowledge HE Smith Company, Inc.’s credit policy *

Yes

I certify that the information on this form is correct. I authorize the release of all pertinent financial and credit information by the listed agencies to verify this information. I release, discharge and exonerate HE Smith Company, its agents, representatives and any party, company or agency which is contacted by HE Smith Company for the purpose of a routine credit check.

I approve the release of financial and credit information. *

Yes

Responsible Party *

Title *

Company

Date *

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