Credit Application

A. APPLICANT

Business Name or Name of Individual if Sole Proprietor

Name*

Email*

Phone*

Fax

Mobile*

Street Address*

Suite

City*

State*

ZIP*

B. PRINCIPALS/OFFICERS

On the Insolvency Field: Please list the year of any bankruptcy or insolvency by principal/officer or any affiliated corporation, LLC, partnership or business.

Name/ Title*

City/ State*

Social Security Number*

Phone*

Any Bankruptcies?*

Date (Enter NA if no Bankruptcies)*

Name/ Title

City/ State

Social Security Number

Phone

Any Bankruptcies?

Date (Enter NA if no Bankruptcies)

C. BILLING INFORMATION

All invoices and statements will be sent to the following email unless otherwise requested.

Email*

Federal Tax ID#/ Employer ID#*

Are Job Names required?*

Yes
No

Are Purchase Orders issued?*

Yes
No

Are you a small business, wholesale merchant or reseller?*

Yes
No

Other Billing Instructions that are important for you?

Are you Sales Tax exempt?*

Yes
No

State/ Tax ID Number*

Please attach exemption Certificate (PDF)*

Drop files here or

Accepted file types: pdf, pdf, Max. file size: 5 MB, Max. files: 5.

D. ABOUT YOUR COMPANY

Attach Financial Statements for the last two years.

Primary Source of Revenue*

Type of Entity*

Estimated Monthly Purchases in US$*

Purchases from Pure Air Control Services.

Date Business started*

Number of Employees*

Date of Incorporation*

State*

DUNS Number*

Financial Statements for last 2 Years (PDF)

Drop files here or

Accepted file types: pdf, pdf, Max. file size: 20 MB, Max. files: 2.

E. BANK REFERENCES

Bank Name*

City*

State*

Account Number*

Phone*

FAX

F. TRADE REFERENCES

Supplier Name 1*

City*

State*

Account Number*

Phone*

FAX

Supplier Name 2

City

State

Account Number

Phone

FAX

Supplier Name 3

City

State

Account Number

Phone

FAX

G. CERTIFICATION

The Applicant certifies the following: (1) the information provided is true and correct and has been submitted as a material inducement to obtain commercial credit; (2) the undersigned is authorized to execute applications and other documents required to establish commercial credit accounts on behalf of Applicant; (3) Seller is hereby authorized to investigate and verify any information provided and inquire of references or others as to ongoing credit worthiness and Seller agrees that this Agreement and Applicant’s extension of credit are subject to continuous credit review and approval; (4) Seller may answer questions from others about its credit experience with the Applicant; and (5) agrees to notify Seller, in writing via certified mail, of any material change in name, ownership, location or corporate status within five (5) days. If Applicant is a partnership or sole proprietorship, then Seller is authorized to obtain and use consumer reports on the Applicant or its principals for the sole purpose of evaluating current or ongoing credit worthiness.

Applicant Signature (First and Last)*

Counts as Electronic Signature

Title*

Date*

Witness Signature (First and Last)

Counts as Electronic Signature

Title

Date

H. PERSONAL GUARANTY

As consideration for the Seller extending credit to the Applicant, the Guarantor(s), jointly and severally hereby personally guarantee the payment of any obligation of the Applicant to the Seller. Therefore, each Guarantor hereby agrees to pay the Seller on demand, without offset, any sum due to the Seller by the Applicant. Guarantor further agrees to pay all costs of collection including reasonable attorney’s fees. This Guaranty shall be a continuing and irrevocable guaranty and indemnity for indebtedness of the Applicant. The Guarantor hereby agrees, to the extent permitted by law, to waive the Homestead exemption, notice of acceptance, notice of presentment, demand, non-payment, dishonor and protest, along with the right to require Seller to proceed against the Applicant. Furthermore, Guarantor consents to and waives notice of any modification, amendment or extension of the terms of the Agreement hereby guaranteed. Guarantor hereby authorizes Seller to obtain and use Consumer Reports from time to time on the Guarantor for the sole purpose of evaluating current and ongoing credit worthiness in connection with the extension of business credit. This Personal Guaranty shall not to exceed five million dollars ($5,000,000) and will remain in force for ten (10) years from date of last sale. Guarantor may revoke this Personal Guaranty only by providing Seller’s Credit Manager written notice via certified mail of its intent to revoke. Revocation shall not relieve Guarantor of obligations incurred prior to receipt of such notice subject to the limit set forth above. Subsequent agreements and credit applications shall not serve to alter, supersede or otherwise modify this Personal Guaranty.

Guarantor 1 Signature (First and Last)

Counts as Electronic Signature

Social Security Number

Date

Guarantor 2 Signature (First and Last)

Counts as Electronic Signature

Social Security Number

Date

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Credit Application

CREDIT APPLICATION