F. D. LAWRENCE ELECTRIC COMPANY
Attn: Credit Department
3450 BEEKMAN STREET
CINCINNATI, OHIO 45223-2743
Page 1 of 3
PHONE# (513) 542-1100
FAX# (513) 542-0649
CREDIT APPLICATION
NAME OF FIRM:_______________________________________________________________________
NAME AND/OR LOCATION OF HEADQUARTERS:_________________________________________
ADDRESS:____________________________________________________________________________
CITY:____________________________________________STATE:________________ZIP:__________
PHONE:______________________________________FAX:____________________________________
WE REQUEST A CREDIT ACCOUNT WITH YOU FOR AVERAGE MONTHLY PURCHASES OF $______________________
GENERAL INFORMATION
FEDERAL TAX IDENTIFICATION NUMBER (FEIN)______________________________________________________________
WE ARE ENGAGED IN THE BUSINESS OF_____________________________________________________________________
THIS BUSINESS WAS ESTABLISHED: YEAR:__________________________________MONTH_________________________
WE ARE A: CORPORATION:__________ PARTNERSHIP:___________ PROPRIETORSHIP__________ LLC______________
THE OWNERS AND/OR OFFICERS ARE:
NAME:_____________________________TITLE_____________________________
NAME:_____________________________TITLE_____________________________
CREDIT REFERENCES
(Note: Including FAX numbers may assist in expediting information promptly.)
FIRM:_________________________________________________________________
PHONE:____________________________
ADDRESS:_____________________________________________________________ FAX:_______________________________
CITY:_____________________________________________STATE:__________________________ZIP:_____________________
FIRM:________________________________________________________________
PHONE:____________________________
ADDRESS:____________________________________________________________
FAX:_______________________________
CITY:____________________________________________STATE:__________________________ZIP:______________________
FIRM:_______________________________________________________________
PHONE:_____________________________
ADDRESS:___________________________________________________________
FAX:________________________________
CITY:____________________________________________STATE_________________________ZIP:________________________
BANK REFERENCE
BANK:______________________________________________________________
PHONE:______________________________
ADDRESS:______________________________________CITY____________________________STATE_______ZIP___________
F. D. LAWRENCE ELECTRIC COMPANY
CREDIT APPLICATION- PAGE 2 of 3
FINANCIAL INFORMATION
FINANCIAL STATEMENT ATTACHED:
_______YES
________NO
Financial statement is not available at this time, but will be sent to you about:
________/_________/_________.
We are:
TAX EXEMPT_________________
TAXABLE_________________
NOTE: TAX EXEMPTION FORM(S) MUST BE ON FILE WITH US TO BE INVOICED NON-TAX,
SO PLEASE SEND A COPY OF THE EXEMPTION CERTIFICATE(S) WITH THIS APPLICATION.
TERMS AGREEMENT
THE PAYMENT FOR ALL SALES OF GOODS OR SERVICES WILL BE 1% 10 TH PROX NET 30
DAYS. THE FAILURE TO PAY ON THE NET DUE DATE ON EACH INVOICE SHALL DEEM THE
DEBT TO BE DELINQUENT. A SERVICE CHARGE MAY BE IMPOSED AT THE RATE OF 1.5%
PER MONTH, OR THE MAXIMUM RATE ALLOWED BY LAW, WHICHEVER IS LESS. THE
UNDERSIGNED AGREES TO PAY ALL COLLECTION COSTS, COURT COSTS AND LEGAL FEES
INCURRED TO COLLECT DELINQUENT BALANCES.
NO TERMS OR CONDITIONS OF ANY PURCHASE ORDER OR SIMILAR DOCUMENT
SUBMITTED BY APPLICANT WILL BECOME PART OF ANY AGREEMENT WITH F. D.
LAWRENCE ELECTRIC COMPANY, UNLESS ACCEPTED IN WRITING.
APPLICANT AUTHORIZES F.D. LAWRENCE ELECTRIC COMPANY TO CONTACT THE
BANK AND TRADE REFERENCES (INCLUDING THOSE LISTED HEREIN) AND ANY
CREDIT REPORTING AGENCIES TO OBTAIN, VERIFY CREDIT INFORMATION.
APPLICANT FURTHER CERTIFIES THAT THE INFORMATION PROVIDED IS TRUE AND
CORRECT:
________________________________________
NAME OF FIRM
TITLE
___________________________________________
SIGNATURE
__________/____________/______________
______________________________________________________
DATE APPLICATION COMPLETED
PRINT (SIGNATURE AND TITLE)
Contact and phone number for Accounts Payable:
Name___________________________Phone__________________
Email Address for Accounts
Payable:_________________________________________________________________
****
Upon completion of this application please mail or fax to: (513) 542-1049
Page 3 of 3
F. D. LAWRENCE ELECTRIC COMPANY
PERSONAL GUARANTEE
In consideration for credit extended, the undersigned contracts and guarantees to the faithful payment when
due, of all accounts of the company seeking credit. This guarantee shall be terminated only on 30 days
written notice to F.D. Lawrence Electric Company, Attn: Credit Dept., 3450 Beekman Street, Cincinnati,
Ohio 45223 and delivered by certified mail. Such termination shall not, however, offset the guarantee
hereby given in respect of any order acknowledged prior to the actual receipt by F.D. Lawrence Electric
Company of said written notice. F.D. Lawrence Electric may exercise its’ rights under this guarantee
without first taking any action against the applicant. The undersigned waives notice of default and
nonpayment and consents to the extension or modification of credit terms to the applicant without notice.
WITNESSES
PERSONAL GUARANTOR
________________________________________
SIGNATURE
________________________________________
PRINT NAME
________________________________________
ADDRESS
________________________________________
CITY
STATE
ZIP
_______________________________________
SIGNATURE
_______________________________________
PRINT NAME
_______________________________________
HOME ADDRESS
_______________________________________
CITY
STATE
ZIP
DATE___________________________________
DATE _________________________________
SOCIAL SECURITY #____________________
________________________________________
SIGNATURE
________________________________________
PRINT NAME
________________________________________
ADDRESS
________________________________________
CITY
STATE
ZIP
________________________________________
SIGNATURE
________________________________________
PRINT NAME
________________________________________
ADDRESS
________________________________________
CITY
STATE
ZIP
DATE __________________________________
DATE __________________________________
SOCIAL SECURITY #____________________
****Please attach a dated personal statement****
PHONE: 513-542-1100
FAX: 513-542-0649