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Billing Address
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Shipping Address
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Disclaimer

Buyer is requesting that Seller provide goods to Buyer on an open account. By signing below, Buyer authorizes Seller to request and obtain a credit report on Buyer with any and all credit reporting agencies deemed appropriate by Seller. This authority shall remain open and valid unless revoked by Buyer in writing, and Seller may periodically request credit reports on Buyer as Seller deems appropriate or necessary. Nothing herein shall require that Seller extend any credit to Buyer whatsoever, and to the extent that Seller does sell any goods to Buyer on account, nothing herein shall require that Seller continue to sell any additional goods to Buyer on account.

Buyer agrees to the above terms of sale and certifies that the facts set forth in the above credit application are true and complete.
Clear Signature
Clear Signature
Date / Time
Date / Time