1Application Information2Contact Information3Trade References4Financial References5TERMS AND CONDITIONS Applicant InformationDate* MM slash DD slash YYYY Legal Business Name* Type of Entity* Corporation Partnership LLC Proprietorship Limited Partnership Federal Tax ID #* State of Registration* Credit Amount Requested ($)* Year of Incorporation* Additional Trade/DBA Name (if any) Parent Company Name (if any) Physical Address* City* State* Zip Code* Mailing Address (if different than above) City State Zip Code Type of Business* Email* Phone*Fax Contact InformationName* Title* Business Phone*Email* Social Security No.* * Owner Partner Officer Home Address* Cell Phone* Name Title Business PhoneEmail Social Security No. Owner Partner Officer Home Address Cell Phone Purchasing Contact* Phone*Email* Accounts Payable Contact* Phone*Email* Trade ReferencesContact Name* Email* Company Name* PhoneAddress Contact Name Email Company Name PhoneAddress Financial ReferencesBank Name* Account #* Contact Name* Phone*Email* Address Are you currently in a bankruptcy proceeding, or have you filed a voluntary bankruptcy or had an involuntary insolvency proceeding filed against you within the last ten years?*---YesNoIf yes, explain Are you currently a party to any lawsuit, or are there any outstanding judgments against you?*---YesNoIf yes, explain TERMS AND CONDITIONSApplicant agrees that all payments shall be made within terms and all past due invoices will bear interest on the unpaid balance at the rate of 1½ % per month (or the maximum allowed by law, whichever is less). If this account is placed for collection, applicant further agrees to pay all collection costs incurred by Bumgarner Propane, including attorney’s fees, court costs, and any contingency for a collection agent. Applicant agrees that the validity and interpretation of this agreement will be governed by the laws of the State of North Carolina. Applicant further agrees that in the event legal action becomes necessary, jurisdiction and venue shall, at Bumgarner Propane’s option, remain in North Carolina. Applicant further agrees that any line of credit desired or approved is not a limitation of liability, and applicant expressly agrees that applicant will be responsible for valid charges in excess of a line of credit either desired or approved. Furthermore, applicant agrees that Bumgarner Propane has the right to refuse future extensions of credit to applicant if applicant fails to comply with any terms or conditions applicable to any sale to applicant. Applicant consents to the verification by Bumgarner Propane of the information supplied in this application and to the exchange of credit information about the applicant now and in the future. Applicant agrees to allow Bumgarner Propane to run a consumer credit report from one of the national credit reporting agencies in order to make a determination of extending credit terms. Applicant hereby knowingly consents to the use of such credit report consistent with the Federal Fair Credit Reporting Act. Applicant agrees that all of the information supplied herein is correct to the best of their knowledge, and that the applicant understands that all goods or services purchased from Bumgarner Propane are subject to the terms and conditions contained in this application and agreement and all other terms and conditions contained on any of Bumgarner Propane’s invoices. Applicant further agrees that all purchases made on this account by its employees or by any other person with actual or apparent authority to make a purchase on this account shall be governed by these terms. Owner/Officer Signature* Date* MM slash DD slash YYYY Print Name of Owner/Officer* Title* CAPTCHA Δ
