HomeMy WebLinkAboutAgreement_General_04/23/2019_SafeliteSafelites Auto Glass
CREDIT
APPLICATION
Mail completed, signed application to: 2400 Farmers Dr, Suite 500, Columbus OH 43235 Date q-lq-j�
To begin processing, you may fax your completed application to 614-210-9686 and then mail the original, signed application to the above address.
BUSINESS TYPE (check one) Proprietorship Partnership— LLC_ Corporation "' Serving Location_ SalesRep
Business Name-Imbote 6-P T-fauei��O- DBA Name
Address — �qj- tieaUL054 6C. Contact Name
City/State/Zip lCa(Aegs t. % Billing Address 13(p briGIT
PL 5..
Telephone City/Sate/Zip U
Date Business Established A/P Telephone Ext
Estimate Annual Purchase
Any Special Billing Requirements?
Request Line
OWNERS, PRINCIPALS AND OFFICERS
Name VAell1011d — SS#
Address
Name
Address
City/State/Zip
SS#
City/State/Zip
Request Terms
Title "Vk, Villooe Maw er
Phone
Title
Phone
BANK AND TRADE REFERENCES q
Bank Name Tt-� ?�a nl,,- City/State/Zip )%uesJra,PL 3'061 Phone,
Trade Ref &Andyl'�, City/State/ZiphAm wa.,R1703 Phone '20 (0 -7;M -R 3 5q (o
T, City/State/Zip 3380a -- Phone 819 -333-75?!5-
TERMS AND CONDITIONS
I/we attest to my/our financial responsibility and ability and willingness to pay Safelite@ Fulfillment, Inc. (SFI) dba Safelite AutoGlass@ or all purchases made by
me/us from SFI according to SN's stated terms. Unless otherwise mutually agreed upon in writing, SFI's stated terms are, "Trie unpaid balance is due in full upon
receipt of the goods." (COO).
1/,We agree that, in the event of legal action instituted to collect any unpaid balance due SFI, I/VVe will pay all costs of collection, court costs and reasonable
attorney's fees incurred by SFI as a result of said legal action. I/We further agree that, in the event any check for payment on my/our accounts is returned unpaid
for any reason, SFI is authorized to assess a Return Check Fee in the amount of $25.00 and to debit my/our account for the amount of said fee, in accordance with
applicable state law.
1,,ANe give my/our consent to any of the bank or trade references listed to release information regarding my/our checking and savings accounts, loans, accounts of
other types of credit transactions. Iffle further authorize SFI to investigate my/our credit worthiness and to obtain reports from any credit reporting bureaus,
BY SIGNING BELOW, VWE CERTIFY THAT VWE HAVE READ -W AWE TO THESIFTfiffIVIS AND CONDITIONS.
Xlamer�v� ig -- u Date
Or be-Viak-C o� +t4e Vilkae tea-4�0
�j &69,ues -mnd-s Lyu&vida a (-rcy
The undersigned unconditionally guarantees the payment when due of all amounts owed by the above named business and waives all notice to which
the undersigned may otherNise be entitled, including but not limited to notice of acceptance, extension of credit and presentment, and consents to
any extension of forbearances.
Name (please prin� Signature Date
N a rn e (please prin 0 Signature Date
tq.