Credit Application Credit Application Your Name(Required) Email(Required) Name of Firm(Required) Corporate Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Billing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Owners Name(Required) Phone(Required)Federal ID Number/Employee Number(Required) Years Incorporated(Required) Dun & Bradstreet Number Working with Sales Rep?(Required) Yes No Sales Rep Name(Required) READ CAREFULLY – This is to certify that our firm is financially able to meet any commitments we have made and to pay our invoices according to our terms of net 30 days. All accounts classified as ‘past due’ will be placed on a C.O.D. basis only until the account is returned to a current status and/or the credit line is re-evaluated. All invoices more than 30 days old may incur an annual interest rate of 18%. There will be a service charge of thirty-five dollars ($35.00) on all returned checks. In the event this account is placed in our Collections Department, applicant agrees to pay all legal and collection costs incurred pursuant to applicable State Laws. Signing this Form is an agreement for my Personal Guaranty of Payment. There is a minimum requirement of one (1) haul per 28 days on all containers. If not hauled or dumped within 28 days, you will be required to pay applicable rental rates.Credit Reference 1Firm Name(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)FaxCredit Reference 2Firm Name(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)FaxCredit Reference 3Firm Name(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)FaxThe information provided above will be held in strict confidentialityDate MM slash DD slash YYYY Accept Electronic Signature I Accept By checking the "I Accept" checkbox and drawing your signature in the signature box, you are signing this credit application electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By checking "I Accept" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. SignaturePrint Name
