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Date

Credit line requested (check one)

Business Name:

DBA:

Address

Address City State ZIP

Phone

Fax

Email

Billing Address if different from above:

Accounts Payable Contact:

Phone

Email

Post Custom Field

Trade references: (Suppliers you have done business with for at least 1 year on credit)

Name

Address

Address City State ZIP

Phone

Fax

Account

Name

Address

Address City State ZIP

Phone

Fax

Account

Name

Address

Address City State ZIP

Phone

Fax

Account

Bank Reference:

Name

Address

Address City State ZIP

Phone

Fax

Account

Firm is a:

Proprietorship
Partnership
Corporation
Franchise
Prior Business Name

State of Incorporation

Date Incorporated:

Tax-exempt #

Firm is a:

Branch
Division
Subsidiary

Federal ID #

D&B #

Of Parent Company

Address, City, State:

If you belong to a membership group please list name and group number

Proprietors, Partners, Officers, Owners:

Name:

Home Address:

Direct Phone:

Name:

Home Address:

Direct Phone:

Name:

Home Address:

Direct Phone:

Terms & Conditions The undersigned (the “Customer”) hereby agrees that all purchases shall be subject to terms and conditions as follows:

Upon Lightbulbsandmore.com, approval of a signed Credit Application. Aplicant may order products as a customer on open account terms and is subject to the complete Terms and Conditions listed on our website lightbulbsandmore.com.
com, credit terms are net (30) days from the date of product shipment. It is the customer's responsibility to insure that the payment is received at the above address. A monthly fee of 1.5% (18% APR) will be assessed each month for unpaid balances exceeding 60 days. Checks in payment for goods that are not honored by the bank shall be subject to a minimum of $25.00 service charge payable to lightbulbsandmore.com.
The customer shall promptly notify com of any change in ownership and/or billing information of the customer, or if the customer files bankruptcy.
If the customer's account becomes past due and lightbulbsandmore.com, a collection agency and/or attorney seeks to collect such past due amounts, then in addition to the amount past due, the customer shall pay to lightbulbsandmore.com, all collections costs,attorney's fees, and any other costs or fees incurred by lightbulbsandmore.com, in order to recover past due amounts owed by the customer, together with the interest at the maximum rate allowed by law.
The customer hereby authorizes the financial or banking institution identified in the credit application to release to lightbulbsandmore.com, credit information relating to the accounts listed.

The customer hereby certifies that all information contained in the credit application is complete , accurate, and truthful.

Name of Authorized Company Signer ( Please print):

Signature and Title:

Date