Name of Business Reply Email






---------------------------------------------------------------------------------------------

Credit References

(two trade references required)


---------------------------------------------------------------------------------------------
Payment Terms:
Payment terms are net ( 15 ) fifteen days from date of invoice. Interest on outstanding balances is charged at the rate of 2% per month.
Service will discontinue on accounts where any portion of the account is 60 days or older.
I authorize and consent to the receipt and exchange of credit and related information.
I fully understand that payment in full must be issued within 15 days from receipt of invoice.
(required)*I accept the above terms

Please leave this field empty.