Credit Application

Home > Contact Us > Credit Application

You can >download the credit application and fax it to Teresa Brown at 386-252-0138, or fill out the form below. Someone will contact you regarding your inquiry.

Business Information
Legal Business Name
Trade Name:
Mailing Address:
Shipping Address:
Fax:
Phone:
Florida Resale Tax Certificate Required (A RESALE TAX CERTIFICATE MUST BE SUBMITTED YEARLY.)	Yes No
Amount of Credit Requested:	$
Do you require a Purchase Order?	Yes No
Person who will be signing checks
Name:
Drivers License Number/State:
Social Security Number:

Type of Business: Proprietorship Corporation LLC Partnership

Business/Organization
Federal Tax ID Number:
D&B Number:
How Long in Business:

Officers/Partners
Name:
Social Security Number:
Position:
Home Address:
Name:
Social Security Number:
Position:
Home Address:
Name:
Social Security Number:
Position:
Home Address:
Trade References
Bank Reference:
Bank Contact:
Reference Name:
Phone:
Fax:
Mailing Address:
Reference Name:
Phone:
Fax:
Mailing Address:
Reference Name:
Phone:
Fax:
Mailing Address:
Terms and Conditions
I understand that I must provide all the information requested in this application and I certify that such information is accurate. I authorize you to verify the information on the application and exchange information on me and the company, including requesting reports from credit reporting agencies. I am aware that this information will be used to determine my/company's eligibility for credit and that if my/company's application is approved, you may contact these sources to update information at any time. The undersigned understands the terms of Ben's Paint Supply are net by 10th. I agree to pay 1.5% monthly service change for all sums owed on the account which are thirty days past due. I and the company agree to pay all collection costs, Including attorney fees, if action is necessary to collect past due amounts. The undersigned personally guarantees payment for all charges made on this account

By typing my name below, it is my intent that it serve as my electronic signature. I further understand and agree that my electronic signature shall have the same force and legal effect as my written signature and that it is my intent to file a credit application electronically with Ben's Paint Supply, LLC (a Florida Limited Liability Company).
Signature of Applicant (Full Name):
Date:

Credit Application

Business Information

Business/Organization

Trade References

Terms and Conditions