Credit Application – C&C Concrete Pumping

Select your region: *

Miami
Dallas
Orlando

COMPANY NAME *

CREDIT REQUESTED: $ *

BUSINESS ADDRESS: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address same as Business Address ?

yes

MAILING ADDRESS: *

Address Line 1

Address Line 2

City

State

Zip Code

PHONE: *

FAX: *

COMPANY CONTACT NAME: *

Cell Phone: *

Email address: *

TYPE: *

FEIN #: *

YEARS IN BUSSINESS: *

ACCOUNTS PAYABLE CONTACT PERSON *

Phone Number: *

Email address: *

PRINCIPALS

Fullname 1 *

Home Address 1 *

Social Security # 1 *

Title 1 *

Fullname 2

Home Address 2

Social Security # 2

Title 2

Fullname 3

Home Address 3

Social Security # 3

Title 3

BANK REFERENCES

Name of Bank: *

Address: *

Telephone: *

Contact Person at Bank: *

Title of Officer *

Account # and Name (Attach Statement): *

TRADE CREDIT REFERENCES

Name: *

Email: *

Acc #:

Name: *

Email: *

Acc #:

Name: *

Email: *

Acc #:

Terms & Conditions *

I have read and agree to the terms and conditions listed below.

I PERSONALLY GUARANTEE PAYMENT FOR ALL PURCHASES WHEN DUE ON THE 30TH DAY AFTER INVOICE DATE. I AGREE TO PAY PROMPTLY. A DELINQUENT CHARGE OF 1.5% MONTHLY FEE WILL BE CHARGED ON ALL PAST DUE BALANCES. BY SIGNING THIS FORM I AUTHORIZE C&C CONCRETE PUMPING TO CHECK ALL REFERENCES MENTIONED IN THIS FORM.

IN THE EVENT IT BECOMES NECESSARY TO INCUR COLLECTION COSTS OR INSTITUTE LEGAL ACTION TO COLLECT ANY AMOUNT DUE UNDER THIS AGREEMENT, OR ANY PORTION THEREOF, THE UNDERSIGNED PROMISES TO PAY SUCH ADDITIONAL COSTS, COURT FILING FEES, ADMINISTRATIVE EXPENSES INCLUDING REASONABLE ATTORNEY’S FEES.

THE LAWS OF THE STATE OF FLORIDA SHALL GOVERN THIS AGREEMENT AND ALL MATERIAL RELATING TO THE PERFORMANCE THEREOF. THE PARTIES HERETO AGREE THAT VENUE FOR THE RESOLUTION OF DISPUTES OR LITIGATION, SHALL BE FILED AND HEARD IN THE COURTS OF MIAMI-DADE COUNTY, FLORIDA.

ANY ALL DISPUTES MUST BE TENDERED IN WRITING TO CORPORATE HEADQUARTERS, 12599 NW 107th AVE, MEDLEY, FL, 33178 WITHIN (10) TEN DAYS FOLLOWING CUSTOMER’S RECEIPT OF INVOICE. FAILURE TO DO SO BY CUSTOMER CONSTITUTES AGREEMENT THAT NO DISPUTE EXISTS.

FULLNAME: *

TITLE: *

Date / Time *

Date

Time

CORPORATE SIGNATURE *

SIGNATURE FOR PERSONAL GUARANTEE *