700 SEMMES AVENUE, SUITE C RICHMOND, VIRGINIA 23224

(804) 233-0113 FAX (804) 233-9187

CREDIT APPLICATION - WRITE CLEARLY & FAX TO (804) 233-9187    Click here to PRINT THIS PAGE

BUSINESS NAME________________________________________________________________________

BILLING ADDRESS_______________________________________________________________________

PHYSICAL ADDRESS_____________________________________________________________________

PHONE NUMBER_____________________________ FAX NUMBER_________________________

CELL PHONE________________________________ E-MAIL________________________________

NAME OF PERSON APPLYING__________________________________________________________________________

( ) CORPORATION ( ) PARTNERSHIP ( ) INDIVIDUAL ( ) LLC

FEDERAL TAX ID # ____________________________

NATURE OF BUSINESS____________________________________ DATE ESTABLISHED________________________

OFFICERS OR OWNERS_______________________________________________________________________________

TITLE, & SOCIAL SECURITY NUMBERS __________________________________________________________________

BANK (NAME, ADDRESS, PHONE, ACCOUNT NUMBER, AND CONTACT)

____________________________________________________________________________________________________

____________________________________________________________________________________________________

CREDIT REFERENCES (NAME, ADDRESS, PHONE, AND FAX)

Name________________________________Name_____________________________Name__________________________

Address______________________________Address___________________________Address_________________________

City/State____________________________City/State__________________________City/State________________________

Telephone____________________________Telephone__________________________Telephone_______________________

Fax__________________________________Fax_______________________________Fax___________________________

Terms:

If credit is approved, we will comply with your normal terms of payment in effect as noted on invoices. It is also acknowledged that a finance charge of 1 ½% per month will be added to any amount not paid within thirty (30) days from the date of invoice and that all expenses incurred in collection amounts owed Bass Crane Service, Inc., including reasonable attorney’s fees will be customer’s responsibility. 

SIGNATURE OF OWNER___________________________________PRINT NAME___________________________________

TITLE____________________________________ DATE________________________________

Payment terms: 1% 10/net 30 – payments must be received within 10 days of invoice to receive 1% discount.