Credit application and Billing Information

Company Name_____________________________________________________
Street Address______________________________________________________
City_______________________________________________ State___________
Mailing Address_____________________________________________________
City________________________________________________ State__________
Phone No._________________________________Fax______________________
Credit limit Desired___________________________________________________
Type of Business_____________________________________________________
Number of Years in Business___________________

Names of Principals or Officers

Name _______________________________________________________________
Position______________________________________________________________
Address_____________________________________________________________
ss#_________________________________________________________________

Name _______________________________________________________________
Position_____________________________________________________________
Address_____________________________________________________________
ss#_________________________________________________________________

Were any Principals in Business Before yes__________ no________
(If yes - Name) ______________________________________________
Address______________________________________________________
Type of Business _____________________________________________
Are Purchase Orders Required yes_________ no___________
Person in Charge of Accounts Payable__________________________
Phone No. _______________________________________
Are you Tax Exempt yes____________ no_________________

If yes attach copy of Tax Exempt Certificate.
Tax Exempt No.__________________________________
Trade References
(Please include Full Address, Inquires are done by mail)

Name _______________________________________________
Address______________________________________________
City_________________________ State____ Zip Code______
Phone No._________________
Fax No.___________________

Name _______________________________________________
Address______________________________________________
City_________________________ State____ Zip Code______
Phone No._________________
Fax No.___________________

Name _______________________________________________
Address______________________________________________
City_________________________ State____ Zip Code______
Phone No._________________
Fax No.___________________

Name _______________________________________________
Address______________________________________________
City_________________________ State____ Zip Code______
Phone No._________________
Fax No.___________________

Bank Name and Branch____________________________________________
Phone No. and contact_____________________________________________

I understand and agree that account balances are due and payable in full on the terms of NET 30.
Accounts not cleared will be put on C.O.D. basis. Past due balances are subject to a 1 _ % monthly finance charge (annual percentage rate of %) or the maximum lawful rate.
A service charge of $25.00 will be assessed on returned checks.
I accept full responsibility of payment of the amounts due Northeast Air Solutions ,Inc. by the above named account and will personally make full payment of the amounts due on the 30th day following purchase if not paid bye the above named account on the due date.

Signature______________________________________ Date___/____/_____
Title______________________________________________________________
Office use only
___________________________________________________________________
Salesman ______________________________
C.L. requested __________
Date ___________________________________
Approved _______________________________
Date ____/____/____
C.L. Approved ___________
Account No. _____________________________________________