1804 NW Martin Road ~ Forest Grove, OR ~ Phone: (503) ~~ Fax: (503) or

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "1804 NW Martin Road ~ Forest Grove, OR ~ Phone: (503) ~~ Fax: (503) or"

Transcription

1 1804 NW Martin Road ~ Forest Grove, OR ~ Phone: (503) ~~ Fax: (503) or NET 30 NEW ACCOUNT APPLICATION Please, complete all Forms. Failure to do so will delay the processing of your application or will result in your account being set up as a COD ACCOUNT automatically. Company s Name Shipping Address Billing Address Telephone # ( ) Fax Number # ( ) Address Applicant Name Applicant Phone # Name of Primary Contact Title Name of Second Contact Title Name of Accounts Payable Contact AP address: AP Phone number (if different) Type of Ownership: Individual: Partnership Corporation If Incorporated, in what state Date of Incorporation Type of Business Wholesale ( ) If different, please specify *If possible, please include a copy of your business license. Federal Tax ID Number # *How would you like to pay? Credit-Card (Visa/Master Card/Discover/AMX) Cashier s Check Wire Transfer/ACH or Company Check The names of all persons owning or controlling interest in the applicant are as follows: Name Address Title Home Phone # SS#

2 BLANKET AUTHORITY TO USE CREDIT CARD This authorizes Oregon Roses, Inc. to use: ( ) Visa ( ) Master Card ( ) Discover ( ) American Express For Payment on any COD or Credit Card shipment unless notified by customer and other payment arrangements are made in advance of shipment, any check returned NSF and $25.00 NSF charge, or in the event of any unpaid invoices 45 days or older not subject to a reimbursement claim or dispute previously documented in writing. Cardholders Name Company Name Card Number Expiration Date Card Address V-Code (3 digit #) *Oregon Roses, Inc., will notify you in writing of any amount that is debited from your credit card. I have read and understand the terms of this agreement and will abide by its terms. Signature of Cardholder Print Name Date *This form must be completed and faxed prior to shipment to Oregon Roses, Inc., at (503) or (503) or mail to 1804 NW Martin Rd. Forest Grove, OR Failure to do so will delay the processing of your application. (Confidential)

3 References I hereby authorize any of the references listed hereon to provide Oregon Roses, Inc., with any and all information requested. Signed Print Name Title Credit Company Name : Contact Person : Address : (Street number and Address) (City) (State) (Zip) Phone Number : Address: Fax Number : Years of doing business: Company Name : Contact Person : Address : (Street number and Address) (City) (State) (Zip) Phone Number : Address: Fax Number : Years of doing business: Company Name : Contact Person : Address : (Street number and Address) (City) (State) (Zip) Phone Number : Address:

4 Fax Number : Years of doing business: Banking: Please provide one banking reference: Bank Name : Account #: Contact Person: Address : Phone Number : Fax Number: The Federal Communications Commission (FCC) issued a new interpretation of the Telephone Consumer Protection Act of 1991 that prohibits sending unsolicited faxes without prior written consent. As of August 25, 2003, you cannot fax anything to your customer and prospects unless you have signed written permission. COMMUNICATIONS CONSENT FORM Name: Company: Address: City State Zip Telephone: ( ) Fax: ( ) I understand that by providing my mailing address, address telephone number and fax number, I consent to receive communications sent by or on behalf of Oregon Roses, Inc., via regular mail, telephone, fax or . I also understand that Oregon Roses, Inc. will not share the provided information with others.

5 Signature Your Title: Date: OREGON ROSES CREDIT APPLICATION AGREEMENT The undersigned hereby agrees and covenants that the information in this application is true and correct as of the date of this application. The undersigned agrees to notify Oregon Roses, Inc., hereafter referred to as ORI on or before the date any information contained in this application becomes incorrect. This credit application shall become binding and effective on the date the undersigned is notified by ORI that the credit application has been approved and an open account has been established of use. The applicant wishes to purchase product from ORI in the future and wishes to open account with ORI according to the terms and conditions contained herein and noted below: 1. Until credit has been established, all orders must be processed in one of three ways: CREDIT CARD prior to shipment (Fill out credit card authority form) COD via cashier s check, or company check (This means the freight carrier MUST accept COD shipments, or the order MUST be prepaid) WIRE transfer or funds 2. To establish credit, complete this credit application. After analyzing credit information received, including reference information, (please allow 1-2 weeks for processing), we will inform you regarding the terms that will be applied to your account including a credit limit if applicable. Our standard terms require payment in full by the 25 th of the month following the

6 month of purchase. A service charge of 1.5 % per month (18% annually) will be assessed on all accounts over 30 days old. 3. Accounts over 60 days will be considered delinquent and are subject to COD and holds on future orders. If it becomes necessary for Oregon Roses, Inc., to institute legal action to enforce collection of any amounts due, Oregon Roses, Inc., shall be entitled to reasonable attorney s fees, court cost, and costs of collection at debtor s expense. The applicant understands and agrees that all billing, accounts and credit functions, and all other business functions are maintained and carried on in Washington County, Oregon. In the event of suit or any dispute about products or services supplied under this agreement, such shall take place in Washington County, Oregon. I have read, understand, and accept the above terms, and have provided true information to the best of my knowledge. Applicant (Signature) (Title) (Date)

Avella Wholesale, Inc.

Avella Wholesale, Inc. Credit Application Form Applicant Information Applicant Name: Address: Company Information Company Name: DBA Name (If Applicable): Company Address: Tax ID (FEINISSN): Billing Contact: Banking Information

More information

BECK EQUIPMENT, INC Preble Rd, Preble, NY Toll Free: (866) / Fax: (607)

BECK EQUIPMENT, INC Preble Rd, Preble, NY Toll Free: (866) / Fax: (607) Legal Company Name BECK EQUIPMENT, INC. RENTAL APPLICATION To apply for rentals from Beck Equipment, Inc., please provide the following information. Fill out completely and return by fax to (607) 749-5640.

More information

RESELLER APPLICATION IMPORTANT NEW ACCOUNT INFORMATION

RESELLER APPLICATION IMPORTANT NEW ACCOUNT INFORMATION Tel : 1 (909) 468-3688 : 1 (909) 628-1755 RESELLER APPLICATION IMPORTANT NEW ACCOUNT INFORMATION Thank you for choosing CG distribution as your premier source of automotive after market lighting and accessories

More information

Royal Group, Inc. or Royal Plastics Group USA Group Company name CREDIT APPLICATION

Royal Group, Inc. or Royal Plastics Group USA Group Company name CREDIT APPLICATION Royal Group, Inc. or Royal Plastics Group USA Group Company name CREDIT APPLICATION Tel:( 905) 652 2780 Fax:( 905) 652 8003 New Application For which Royal Group Company Credit Update Please select the

More information

NEW CUSTOMER SETUP All fields must be filled out, any supporting documents must be forwarded with request form. City: State: Zip:

NEW CUSTOMER SETUP All fields must be filled out, any supporting documents must be forwarded with request form. City: State: Zip: Palletized Trucking Inc. Accounting PO Box 8744 Houston, TX 77249 8744 713 225 3303 NEW CUSTOMER SETUP All fields must be filled out, any supporting documents must be forwarded with request form CUSTOMER

More information

LYNCH OIL COMPANY, INC. Toll Free (800) P.O. BOX Fax (407) KISSIMMEE, FLORIDA

LYNCH OIL COMPANY, INC. Toll Free (800) P.O. BOX Fax (407) KISSIMMEE, FLORIDA Thank you for your interest in opening an account with Lynch Oil! Please find all necessary documents attached, with explanations for each below. Required fields are highlighted. Incomplete applications

More information

Attached are an original credit application, financial statement format and Appendix B explaining our draft payment plan.

Attached are an original credit application, financial statement format and Appendix B explaining our draft payment plan. Norfolk Southern Corporation Randy L. Shilling Brenda Taylor Treasury Department Assistant Treasurer & Credit Manager Assistant Credit Manager 3 Commercial Place (757) 629-2731 (757) 533-4809 Norfolk,

More information

WHY SPIRITUS? Some of our Vendors

WHY SPIRITUS? Some of our Vendors Spiritus Distribution is the Catholic division of New Day Christian, an independently owned distribution company that has served the evangelical Christian market for over 30 years. Spiritus provides the

More information

IMS Company Terms and Conditions of Sale

IMS Company Terms and Conditions of Sale IMS Company Terms and Conditions of Sale Seller s Terms and Conditions of Sale apply to all purchases made by Buyer from Seller and all Invoices, emails, packing lists, or any other method of confirming

More information

*** N E W C A S H - CC A C C O U N T A P P L I C A T I O N * * *

*** N E W C A S H - CC A C C O U N T A P P L I C A T I O N * * * *** N E W C A S H - CC A C C O U N T A P P L I C A T I O N * * * Are you applying for a Business Account or Personal Account? To expedite the processing of your application please include copies of all

More information

BUSINESSMAX MEMBERSHIP APPLICATION

BUSINESSMAX MEMBERSHIP APPLICATION One Leo Fraser Dr., Northfield, NJ 08225 ottingergolf.com Atlantic City CC: 609-236-4400 Ballamor GC: 609-601-6220 Scotland Run GC: 856-863-3737 BUSINESSMAX MEMBERSHIP APPLICATION Company Name: Business

More information

BUSINESS ACCOUNT APPLICATION

BUSINESS ACCOUNT APPLICATION BUSINESS ACCOUNT APPLICATION Company Name Type of Business: Maintenance Address Contractor Non Profit City, State, Zip Condo Assn Prop Mgmt. Contact Education Religious Phone # Fax # Hotel Restaurant Email

More information

THANK YOU FOR YOUR INTEREST IN BILL HICKS & CO., LTD

THANK YOU FOR YOUR INTEREST IN BILL HICKS & CO., LTD BILL HICKS & CO., LTD. Office: (763) 476-6200 15155 23 RD Avenue North Fax: (763) 476-8963 Minneapolis, Minnesota 55447-4740 Toll Free: (800) 223-0702 THANK YOU FOR YOUR INTEREST IN BILL HICKS & CO., LTD

More information

CREDIT APPLICATION. Billing Address City: State: Zip: Shipping Address City: State: Zip: DBA: Established:

CREDIT APPLICATION. Billing Address City: State: Zip: Shipping Address City: State: Zip: DBA: Established: KONA FISH COMPANY, INC. 55 Holomua St. ~ Hilo, Hawaii 96720 Phone: (808) 961-0877 ~ Fax: (808) 934-8783 Email: accounting@konafish.com ~ Internet: www.konafish.com Requested Credit Limit: CREDIT APPLICATION

More information

Your interest in material and service is appreciated and we thank you for your cooperation in the above matter.

Your interest in material and service is appreciated and we thank you for your cooperation in the above matter. Desert Electric Supply MAIN OFFICE, 74-875 VELIE WAY 83311 AVE 45; STE 102 4605 E. SUNNY DUNES ROAD PALM DESERT, CA 92260 INDIO, CA 92201 PALM SPRINGS, CA 92264 (760) 568-5991 (760) 404-0010 (760) 327-1146

More information

Application for Customer Status

Application for Customer Status Application for Customer Status TERMS AND CONDITIONS OF SALES: The terms and condition of sales by Perfect 10 (hereafter referred to as Perfect 10 ) to the below named Customer (hereafter referred to as

More information

3776 S.R. 93 N.E., Crooksville, OH Toll Free (866) * Phone (740) * Fax (740)

3776 S.R. 93 N.E., Crooksville, OH Toll Free (866) * Phone (740) * Fax (740) 3776 S.R. 93 N.E., Crooksville, OH 43731 Toll Free (866) 818-4435 * Phone (740) 982-3030 * Fax (740) 982-3055 www.valueautoauction.com Name of Dealer: Telephone ( ) (Legal Name if Different) Fax# ( ) (Hereinafter

More information

CARRIER ENTERPRISE NORTHEAST, LLC ( CE ) (PLEASE PRINT CLEARLY) Credit Agreement

CARRIER ENTERPRISE NORTHEAST, LLC ( CE ) (PLEASE PRINT CLEARLY) Credit Agreement CARRIER ENTERPRISE NORTHEAST, LLC ( CE ) Date Credit Agreement (PLEASE PRINT CLEARLY) Company Name of Applicant (If applicant is a corporation or LLC, give name as it appears in the ARTICLES OF INCORPORATION)

More information

Quality Linens That Cost Less!

Quality Linens That Cost Less! Quality Linens That Cost Less! Thank you for your interest in A-1 Tablecloth Company Enclosed are the forms to setup your account. Please take a moment to review. Page 2, Credit card form Must be filled

More information

JOINT ACCOUNT. Last Name: First Name: Initial: Date of Birth: Street Address: City, State, Zip: County:

JOINT ACCOUNT. Last Name: First Name: Initial: Date of Birth: Street Address: City, State, Zip: County: CREDIT APPLICATION Location submitting application: MFA OIL COMPANY MFA PETROLEUM COMPANY One Ray Young Drive Columbia, MO 65201 INDIVIDUAL ACCOUNT Complete Parts 1, 4 and 5 if you are applying for an

More information

STUDENT REGISTRATON. Emergency Contact: Medical conditions / allergies: Yes No If yes, please explain: Parent/Guardian's Signature:

STUDENT REGISTRATON. Emergency Contact: Medical conditions / allergies: Yes No If yes, please explain: Parent/Guardian's Signature: STUDENT REGISTRATON Student's Name: Age: Male/Female: of Birth: / / Are you a returning Footworks student (Y/N)? Years dance experience: E-mail address: How did you hear about us? (circle) WO TIMES-SW

More information

Instructions for Completing the Customs Power of Attorney

Instructions for Completing the Customs Power of Attorney Instructions for Completing the Customs Power of Attorney 1. Check the box that describes the status of your business. Foreign Company - Check the "Corporation" box. 2. Enter your Federal Tax ID number

More information

CONSULTING AGREEMENT. Affordable Wireless Solutions

CONSULTING AGREEMENT. Affordable Wireless Solutions CONSULTING AGREEMENT SERVICES AND CONSULTING RATES & FEES $175/hr $315/hr $87.5/hr Travel Expenses Reimbursement: 1. Mileage, in excess of 20 miles traveled per day, reimbursed per the most recent IRS

More information

STANDARD TERMS AND CONDITIONS

STANDARD TERMS AND CONDITIONS STANDARD TERMS AND CONDITIONS Zebra Technologies International, LLC Unless Zebra Technologies International, LLC ( ZEBRA ) otherwise agrees in writing, the following terms and conditions ( T&Cs ) shall

More information

Welcome Home! Valid state issued photo identification and a social security card.

Welcome Home! Valid state issued photo identification and a social security card. Welcome Home! In order for us to process your application in the quickest manner possible, we will need the following items when you submit your application. Two most recent pay stubs. Income must be equal

More information

OWNER'S OF COMPANY INFORMATION

OWNER'S OF COMPANY INFORMATION 36 West 47 th Street Suite 1206 New York, NY 10036 phone# (212) 944-5776 fax# (888) 269 9029 customerservice@pafcocasting.com CUSTOMER INFORMATION Company name Company address City State Zip code Phone#

More information

Company Name Booth. Contact Name. Phone Fax. Contact

Company Name Booth. Contact Name. Phone Fax. Contact RENTAL FURNISHINGS CHAIRS ROUND PEDESTAL TABLES QTY ADVANCE STANDARD AMOUNT QTY ADVANCE STANDARD AMOUNT UPHOLSTERED ARM CHAIR $54.00 $65.00 ROUND TABLE - 30 X 30 H $158.00 $202.50 UPHOLSTERED SIDE CHAIR

More information

PHYSICAL THERAPY WELCOME PACKET

PHYSICAL THERAPY WELCOME PACKET PHYSICAL THERAPY WELCOME PACKET Thank you for choosing Michael Johnson Physical Therapy. This welcome packet contains six forms. Please see instructions below and complete the forms accordingly. 1. New

More information

Iridium Post-paid Agreement

Iridium Post-paid Agreement Address: 8637 E Sandalwood Dr Scottsdale, AZ 85250 Phone: 1-888-596-8735 Iridium Post-paid Agreement Intl: 1-480-348-0442 Fax: 1-425-940-4691 Section A - Tempest Telecom Terms & Conditions Equipment Sales

More information

E-Teller In Branch Paper Statement Statement Visa Fraud Prevention Phone MSR. Other:

E-Teller In Branch Paper Statement  Statement Visa Fraud Prevention Phone MSR. Other: Account Number: Last 4 Digits of Card: Card Fraud Questionnaire How did you discover the fraudulent transactions on your account? (Circle One) E-Teller In Branch Paper Statement Email Statement Visa Fraud

More information

BBVA Compass VISA BUSINESS CARD MASTER AGREEMENT & SECURITY AGREEMENT

BBVA Compass VISA BUSINESS CARD MASTER AGREEMENT & SECURITY AGREEMENT BBVA Compass VISA BUSINESS CARD MASTER AGREEMENT & SECURITY AGREEMENT This Agreement should be read carefully and maintained in the Business records. This Visa Business Card Master Agreement (the "Agreement")

More information

Milestone AV Technologies LLC Corporate Address: 6436 CITY WEST PKWY., EDEN PRAIRIE, MN USA

Milestone AV Technologies LLC Corporate Address: 6436 CITY WEST PKWY., EDEN PRAIRIE, MN USA Milestone AV Technologies LLC Corporate 6436 CITY WEST PKWY., EDEN PRAIRIE, MN 55378 USA ACCOUNT REQUIREMENTS W MILESTONE.COM REQUIREMENTS 1. Complete Account Application. PLEASE PRINT CLEARLY & LEGIBLY

More information

BRETT P. TERRIEN, LMHC

BRETT P. TERRIEN, LMHC 617.470.5404 BRETT@TERRIENLMHC.COM INTAKE INFORMATION Name Date Street Address City/State/Zip Email Marital Status Date of Birth Referred By Phone Work Phone Preferred contact: Phone Work Phone Email Insurance

More information

VISA CREDIT CARD Application Form OAS Staff FCU 1889 F Street, NW Washington, DC Tel: Fax:

VISA CREDIT CARD Application Form OAS Staff FCU 1889 F Street, NW Washington, DC Tel: Fax: VISA CREDIT CARD Application Form OAS Staff FCU 1889 F Street, NW Washington, DC 20006 Tel: 202-458-3834 Fax: 202-478-1592 Member Number Choose the right one for you! Visa Classic Visa Platinum APPLICANT

More information

STANDARD TERMS & CONDITIONS OF SALE

STANDARD TERMS & CONDITIONS OF SALE STANDARD TERMS & CONDITIONS OF SALE THE SALE OF PRODUCTS AND SERVICES ("PRODUCTS") BY ABACUS TECHNOLOGIES, ARE SUBJECT TO THESE TERMS AND CONDITIONS ("AGREEMENT") REGARDLESS OF OTHER OR ADDITIONAL TERMS

More information

Thank you for your interest in becoming a customer of Southern Glazer's Wine & Spirits of Nevada

Thank you for your interest in becoming a customer of Southern Glazer's Wine & Spirits of Nevada New Account Forms Thank you for your interest in becoming a customer of Southern Glazer's Wine & Spirits of Nevada Please download, complete and submit the following forms to: New Account Credit Agent

More information

HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION

HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION Thank you for choosing our office. In order to serve you properly, we will need the following information. PLEASE PRINT: Name: Date: (Parents/caregivers):

More information

BILL L. JOU, M.D., INC.

BILL L. JOU, M.D., INC. BILL L. JOU, M.D., INC. AUTHORIZATION TO TREAT I (and/or the undersigned on behalf of the patient) voluntarily consent to allow Dr. Bill L. Jou and staff to provide such evaluation and/or care and treatments

More information

SEED CAPITAL CORP BUSINESS CONSULTING SERVICES AGREEMENT

SEED CAPITAL CORP BUSINESS CONSULTING SERVICES AGREEMENT SEED CAPITAL CORP BUSINESS CONSULTING SERVICES AGREEMENT This Business Consulting Services Agreement (this "Agreement"), dated as of, 201 (the Effective Date ), is between and among, an individual residing

More information

BBVA Compass Commercial Card Agreement

BBVA Compass Commercial Card Agreement BBVA Compass Commercial Card Agreement Company: Date: THIS COMMERCIAL CARD AGREEMENT (the Agreement ) is made and entered into as of the date set forth above by the company whose name is set forth above

More information

Allied Loan Servicing, LLC 1000 Caughlin Crossing, Suite 30 Reno, Nevada (p) or (f)

Allied Loan Servicing, LLC 1000 Caughlin Crossing, Suite 30 Reno, Nevada (p) or (f) LOAN SERVICING AGREEMENT The undersigned hereby give their authorization to establish a Loan Servicing Account & do hereby deposit, or have deposited on their behalf, with Allied Loan Servicing, the following

More information

Welcome to the DT Global, Inc family. Establishing open terms will allow the most efficient method of product purchase and delivery.

Welcome to the DT Global, Inc family. Establishing open terms will allow the most efficient method of product purchase and delivery. DT Global, lnc NEW ACCOUNT Welcome to the DT Global, Inc family. Establishing open terms will allow the most efficient method of product purchase and delivery. Please read and complete the enclosed forms

More information

SELECT SOURCE TERMS AND CONDITIONS

SELECT SOURCE TERMS AND CONDITIONS SELECT SOURCE TERMS AND CONDITIONS In the course of its business, Reseller will purchase Ingram Micro Products and will sell Ingram Micro Products to customers located in the United States ( End Users

More information

Retail Services Agreement

Retail Services Agreement CERTIFIED FORENSIC LOAN AUDITORS, LLC 13101 West Washington Blvd., Suite 140 Los Angeles, CA 90066 Phone: 310-432-6304 Facsimile: 310-432-6303 sales@certifiedforensicloanauditors.com www.certifiedforensicloanauditors.com

More information

NATIONAL INSURANCE UNDERWRITERS, LLC. AUTO PRODUCER S AGREEMENT

NATIONAL INSURANCE UNDERWRITERS, LLC. AUTO PRODUCER S AGREEMENT NATIONAL INSURANCE UNDERWRITERS, LLC. AUTO PRODUCER S AGREEMENT This Agreement between National Insurance Underwriters, LLC., with principle offices located at 800 Yamato Road, Suite 100, Boca Raton, FL

More information

FlexGift Loyalty Agreement

FlexGift Loyalty Agreement FlexGift Loyalty Agreement NEW LOYALTY ONLY EXISTING MID Business Information DBA Name Legal Name Physical Street Address Legal Address (if different from physical) Mailing Address City, State, Zip City,

More information

PATIENT APPLICATION FORM

PATIENT APPLICATION FORM PATIENT APPLICATION FORM WELCOME TO OUR CLINIC! We specialize in assisting our patients to achieve their highest level of health through our spinal and postural corrective programs. Our approach is very

More information

APPLICATION FOR MEMBERSHIP PRIVILEGES

APPLICATION FOR MEMBERSHIP PRIVILEGES The undersigned hereby applies for a membership at Spring Creek Golf Club. If approved, the undersigned requests that his/her name be placed on the Membership Roster as follows. MEMBERSHIP INFORMATION

More information

CHAPTER FOUR ORIGIN PROCEDURES

CHAPTER FOUR ORIGIN PROCEDURES CHAPTER FOUR ORIGIN PROCEDURES ARTICLE 4.1: CERTIFICATE OF ORIGIN 1. Each Party shall grant preferential tariff treatment in accordance with this Agreement to an originating good imported from the territory

More information

Application for Credit

Application for Credit Application for Credit MetalSource A Subsidiary of M-D Building Products Inc. Firm Name Street Address Mailing Address County City State Zip Phone Fax No. Email Address Duns Number CREDIT INFORMATION (List

More information

PNC Bank, National Association, which issues your Credit Card. The billing cycle or billing cycles of your Credit Card Account

PNC Bank, National Association, which issues your Credit Card. The billing cycle or billing cycles of your Credit Card Account K-9397 points PNC Flex T&C 6/17 PNC points Program Terms and Conditions as of June 18, 2017 Basic terms defined Program Credit Card, Card Credit Card Account You, your, Cardholder We, our, us, PNC Bank,

More information

WORKSHEET FOR 501(c)(3)

WORKSHEET FOR 501(c)(3) WORKSHEET FOR 501(c)(3) Consultant: Affiliate: Affiliate Code: Phone: Date: Nevada Post Office Box (additional fees apply) YES NO Assignment of Assets (additional fees apply) YES NO 1. CLIENT CONTACT INFORMATION:

More information

(continued on reverse)

(continued on reverse) FOR OFFICE USE ONLY: ACCOUNT NUMBER: PROCESSED BY: DATE: Welcome to the Port of Hood River BreezeBy prepaid electronic tolling system. Please complete this application form, sign, and return it to the

More information

Processor Service Agreement

Processor Service Agreement /////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////////// For NatPay Use Only Rep: Type: Reg PPP

More information

Complete Credit Application (please print clearly and check for signatures) New Dealer Application (please print clearly and check for signatures)

Complete Credit Application (please print clearly and check for signatures) New Dealer Application (please print clearly and check for signatures) We are delighted that you are interested in becoming a Tucker Rocky and Biker s Choice Dealer. There are a few documents and some information that we need to start the process. Please use the check list

More information

SAFE Visa Business Credit Card

SAFE Visa Business Credit Card SAFE Visa Business Credit Card PRICING INFORMATION Variable rates are based on the Prime Rate as of March 28, 2018. Annual Percentage Rate (APR) for Purchases Rates based on the Prime Rate Annual Percentage

More information

Customer Application Cover Page. Customer Name:

Customer Application Cover Page. Customer Name: Customer Application Cover Page Customer Name: Form ID Document # of Documents Received DAPU Application for Customer Status Publicly Owned PO Principals and Owners BT Bank and Trade Information TC Terms

More information

DEALER AGREEMENT WITH STANDARD TERMS AND CONDITIONS OF SALE

DEALER AGREEMENT WITH STANDARD TERMS AND CONDITIONS OF SALE Page 1 of 5 DEALER AGREEMENT WITH STANDARD TERMS AND CONDITIONS OF SALE This Dealer Agreement with Standard Terms and Conditions of Sale (this Agreement ) is made and entered into on the date indicated

More information

Lexington Law Firm Payment Information Form

Lexington Law Firm Payment Information Form Lexington Law Firm Payment Information Form A Valid Active Email Address Is Required. Please Print Your Email Address Below PERSONAL INFORMATION FIRST NAME: LAST NAME: ADDRESS: CITY: HOME PHONE: WORK PHONE:

More information

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax:

Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA Phone Fax: Christina Agustin, MD Board Certified in Adult Psychiatry 1 Lake Bellevue Drive, Suite 101 Bellevue, WA 98005 Phone 425-301-9869 Fax: 866-546-1618 Welcome to my practice. I look forward to meeting with

More information

ACCEPTANCE OF CONTRACT/TERMS AND CONDITIONS

ACCEPTANCE OF CONTRACT/TERMS AND CONDITIONS 1. ACCEPTANCE OF CONTRACT/TERMS AND CONDITIONS 1.1. This Contract together with its referenced Exhibits, supersedes any prior offers, negotiations, and agreements concerning the subject matter hereof and

More information

POWER OF ATTORNEY/ DESIGNATION OF EXPORT FORWARDING AGENT And Acknowledgement of Terms and Conditions. Account Executive:

POWER OF ATTORNEY/ DESIGNATION OF EXPORT FORWARDING AGENT And Acknowledgement of Terms and Conditions. Account Executive: POWER OF ATTORNEY/ DESIGNATION OF EXPORT FORWARDING AGENT And Acknowledgement of Terms and Conditions Legal status of issuing party Check appropriate box Individual Partnership Corporation Sole Proprietorship

More information

CREDIT APPLICATION. I,, on behalf of, apply for credit with Gagne & Son Concrete Block, Inc.

CREDIT APPLICATION. I,, on behalf of, apply for credit with Gagne & Son Concrete Block, Inc. CREDIT APPLICATION I,, on behalf of, apply for credit with Gagne & Son Concrete Block, Inc. Applicant certifies that the following information is accurate: ALL QUESTIONS MUST BE ANSWERED COMPLETELY IN

More information

Accushield Registration Guide

Accushield Registration Guide Accushield Registration Guide Welcome to Accushield! You are now part of a network of companies with the highest standards of safety and security in the senior living industry. As an Accushield credentialed

More information

16.74% After that, your APR will be 16.74%. This APR will vary with the market based on the Prime Rate % Maximum APR 29.99%

16.74% After that, your APR will be 16.74%. This APR will vary with the market based on the Prime Rate % Maximum APR 29.99% UBS VISA INFINITE CREDIT CARD ACCOUNT SUMMARY TABLE Interest Rates and Interest Changes Annual Percentage Rate (APR) for Purchases 16.74% This APR will vary with the market based on the Prime Rate. APR

More information

Welcome To Our Office

Welcome To Our Office Welcome To Our Office Since 1977 The Miami Counseling & Resource Center ( MCRC ) is a large, private Center that has been helping individuals, couples, and families in Miami for over 30 years, and we are

More information

Standard Credit Package Attn: Brenda Koch Ph.:

Standard Credit Package Attn: Brenda Koch Ph.: Standard Credit Package Attn: Brenda Koch Ph.: 281.597.5479 In order to expedite your request, please include the following: 1. A completed and signed credit application. If you have your credit information

More information

APPLICATION FOR REGULAR MEMBERS

APPLICATION FOR REGULAR MEMBERS 2013 APPLICATION FOR REGULAR MEMBERS The undersigned hereby makes application for membership in Toy Industry Association, Inc., with the understanding that this membership will remain in force until formally

More information

PNC Virtual Wallet with Performance Select Features and Fees

PNC Virtual Wallet with Performance Select Features and Fees PNC Virtual Wallet with Performance Select Features and Fees Effective December 10, 2017 Delaware, Florida, Illinois (excluding Boone, Cook, DeKalb, DuPage, Kane, Kankakee, Lake, McHenry, Will and Winnebago

More information

Spouse/Parent s Name Date of Birth / / Age Sex Relation to client Social Security # Phone Employed by Phone

Spouse/Parent s Name Date of Birth / / Age Sex Relation to client Social Security # Phone Employed by Phone Patient Information *ALL FIELDS NEEDED TO PROCESS CLAIM *Patient s Name * Address *Zip Code *Social Security Number / / Telephone (Home) (Work) (Cell) * Email address *Date of Birth / / Age Sex Marital

More information

Upgrade My Credit Client Agreement

Upgrade My Credit Client Agreement Upgrade My Credit Client Agreement 901 W. Bardin Rd. Suite 306 Arlington, Texas 76017 817-886-0302 off. 817-887-0816 fax www.upgrademycredit.com APPLICANT INFORMATION Mr. Mrs. Ms. PLEASE PRINT CLEARLY

More information

CONSUMER CREDIT CARD AGREEMENT

CONSUMER CREDIT CARD AGREEMENT CUNA Mutual Group 1991, 2006, 09, 10, 12 All Rights Reserved CONSUMER CREDIT CARD AGREEMENT In this Agreement, Agreement means this Consumer Credit Card Agreement. Disclosure means the Credit Card Account

More information

Oneplan Standard Terms & Conditions. Effective Date: 1 April 2017 Version: 2.0

Oneplan Standard Terms & Conditions. Effective Date: 1 April 2017 Version: 2.0 1 Oneplan Standard Terms & Conditions Underwritten by Effective Date: 1 April 2017 Version: 2.0 I, the undersigned, hereby warrant: DISCLOSURES: That all intermediary (Oneplan Brokers (PTY) Ltd), Administrator

More information

Independent Contractor Agreement with Health Care Worker. Agreement made on the day of, 20, between (Contractor) of

Independent Contractor Agreement with Health Care Worker. Agreement made on the day of, 20, between (Contractor) of Independent Contractor Agreement with Health Care Worker Agreement made on the day of, 20, between (Contractor) of (street address, city, county, state, zip code), referred to herein as Contractor, and

More information

Allcare Rehabilitation

Allcare Rehabilitation Allcare Rehabilitation Welcome to Allcare Rehabilitation, Inc. Please complete the following information as accurately as possible as it is necessary we have this information to effectively file your insurance

More information

Patient Order Form STEP 2. gammacore.de 1 / 2. Ordering Process. Contact Information. Phone (mandatory) Customer ID#

Patient Order Form STEP 2. gammacore.de 1 / 2. Ordering Process. Contact Information. Phone (mandatory) Customer ID# Please return the completed form to Loxxess Pharma GmbH on belhaf of Hotline +49 (0) 8171 483 58 300 E-Mail auftrag@loxxess-pharma.com Ordering Process STEP 2 Authorization Form must be sent first Patient

More information

DISTRIBUTOR AND INTERNATIONAL SPONSOR AGREEMENT ITALY

DISTRIBUTOR AND INTERNATIONAL SPONSOR AGREEMENT ITALY DISTRIBUTOR AND INTERNATIONAL SPONSOR AGREEMENT ITALY This Distributor and International Sponsor Agreement is between Nu Skin International, Inc., a Utah corporation, 75 West Center Street, Provo, Utah

More information

If you have the need to hire a contract hauler and would like to allow them to charge to your account, the following requirements apply.

If you have the need to hire a contract hauler and would like to allow them to charge to your account, the following requirements apply. KERN COUNTY PUBLIC WORKS DEPARTMENT CRAIG M. POPE, P.E., DIRECTOR ADMINISTRATION & ACCOUNTING OPERATIONS & MAINTENANCE BUILDING & DEVELOPMENT ENGINEERING 2700 M STREET BAKERSFIELD, CA 93301-2370 Phone:

More information

ATLANTIC CONCRETE PRODUCTS, INC.

ATLANTIC CONCRETE PRODUCTS, INC. P.O. Box 129 Tullytown, PA 19007-0098 Tel.(215) 945-5600 Fax (215) 945-5016 CREDIT APPLICATION DATE: TOTAL PAGES: 1 of 5 TO: FROM: Steve Schlussel Accts Receivable Mgr COMPANY: COMPANY: Atlantic Concrete

More information

BP MS 150 BIKE TOUR 4/ RENTAL ORDER FORM

BP MS 150 BIKE TOUR 4/ RENTAL ORDER FORM Please fill out the form and email to Ashley Blake @ ashley.blake@aztecusa.com if you have any questions please call @ (713)699-0088. DEADLINE TO SUBMIT THIS FORM IS FEBRUARY 13, 2017. PLEASE MAKE NOTE

More information

2018 Tech-Security Conferences website

2018 Tech-Security Conferences website Please indicate your sponsorship level next to the appropriate city. City Los Angeles 3/22/18 Toronto 3/29/18 Dallas 4/4/18 General Session 45 minutes $4000 General Session 30 minutes $3500 Registration

More information

ELECTRONIC FUND TRANSFERS AGREEMENT AND DISCLOSURE

ELECTRONIC FUND TRANSFERS AGREEMENT AND DISCLOSURE ELECTRONIC FUND TRANSFERS AGREEMENT AND DISCLOSURE This Electronic Fund Transfers Agreement and Disclosure is the contract which covers your and our rights and responsibilities concerning the electronic

More information

If you are a reseller of products, you must also include a copy of your state tax ID form.

If you are a reseller of products, you must also include a copy of your state tax ID form. Dear Customer: Thank you for interest in a trade account with TrucknTow. It is our goal to process your application as quickly as possible. In order to process your application in the most efficient manner,

More information

Visa Rewards Platinum. Visa Platinum. Visa Platinum Secured. Visa Platinum. Visa Platinum Secured. Visa Platinum. Visa Platinum Secured

Visa Rewards Platinum. Visa Platinum. Visa Platinum Secured. Visa Platinum. Visa Platinum Secured. Visa Platinum. Visa Platinum Secured VISA REWARDS PLATINUM/VISA PLATINUM/VISA PLATINUM SECURED F1 APPLICATION AND SOLICITATION DISCLOSURE Interest Rates and Interest Charges Annual Percentage Rate (APR) for Purchases Visa Rewards Platinum

More information

SELF-HELP CREDIT UNION CREDIT CARD ACCOUNT AGREEMENT

SELF-HELP CREDIT UNION CREDIT CARD ACCOUNT AGREEMENT This Credit Card Account Agreement (this Agreement ) contains the terms of your Self-Help Credit Union Credit Card and starts as soon as you sign or use the card. The Credit Card Account Opening Disclosure

More information

Supplier Profile Form

Supplier Profile Form Supplier Profile Form All new suppliers must be qualified prior to any purchases being made. Please complete the following form and email to purchasingdept@thompsontractor.com or fax to 205-226-6203. Once

More information

MASTERCARD REWARDS/MASTERCARD CASHBACK CONSUMER CREDIT CARD AGREEMENT

MASTERCARD REWARDS/MASTERCARD CASHBACK CONSUMER CREDIT CARD AGREEMENT MASTERCARD REWARDS/MASTERCARD CASHBACK CONSUMER CREDIT CARD AGREEMENT In this Agreement, Agreement means this Consumer Credit Card Agreement. Disclosure means the Credit Card Account Opening Disclosure.

More information

August 18, am - 6 pm Bayside Park, Chula Vista Contact NON-FOOD VENDOR APPLICATION

August 18, am - 6 pm Bayside Park, Chula Vista Contact NON-FOOD VENDOR APPLICATION Non-Food App. Pg. 1 August 18, 2018 10 am - 6 pm Bayside Park, Chula Vista Contact ed@edwindecker.com 619-261-5664 NON-FOOD VENDOR APPLICATION PLEASE WRITE LEGIBLY BUSINESS / ORGANIZATION: CONTACT PERSON(S):

More information

5. 2 months most recent Bank Statements- all pages w/ name & account # visible

5. 2 months most recent Bank Statements- all pages w/ name & account # visible INITIAL DOCUMENTATION CHECKLIST 1. Loan Application* 2. Letter of Experience & Explanation* 3. Investor Portfolio & Schedule of Real Estate Owned* 4. Credit Card Authorization Form (295 for BPO)* 5. 2

More information

TRUTH-IN-SAVINGS DISCLOSURE

TRUTH-IN-SAVINGS DISCLOSURE LAST DIVIDEND DECLARATION DATE: 11/30/2016 TRUTH-IN-SAVINGS DISCLOSURE The rates, fees and terms applicable to your account at the Credit Union are provided with this Truth-in-Savings Disclosure. The Credit

More information

A Guide to Your Share Account**

A Guide to Your Share Account** Deposit Account Disclosure Important Notices A Guide to Your Share Account** explain the additional banking services and fees for your Share Account(s). Regular Share (includes $avar Account) Travel Share

More information

Health Savings Account Application

Health Savings Account Application Form 004 Page 1 of 9 When to use this form: Use this form to open a Health Savings Account only. To complete your HSA : Mail your completed HSA package to: CamaPlan 122 E. Butler Ave, Suite 100 Ambler,

More information

SECONDARY CARDHOLDER USER GUIDE IMPORTANT PLEASE READ CAREFULLY

SECONDARY CARDHOLDER USER GUIDE IMPORTANT PLEASE READ CAREFULLY SECONDARY CARDHOLDER USER GUIDE IMPORTANT PLEASE READ CAREFULLY smione Visa Prepaid Card User Guide for Secondary Cardholders This document ( User Guide ) outlines the terms of the smione Visa Prepaid

More information

State of New Jersey Department of Banking & Insurance. Annual Report Worksheet for Consumer Lenders. Year Ending December 31, 2016

State of New Jersey Department of Banking & Insurance. Annual Report Worksheet for Consumer Lenders. Year Ending December 31, 2016 State of New Jersey Department of Banking & Insurance for Consumer Lenders New Jersey Department of Banking & Insurance Division of Banking Attn: Sharon Davis -- 5 th floor 20 West State Street Trenton,

More information

ISPFCU VISA PLATINUM PROGRAMS TERMS AND CONDITIONS The information about the costs of the card described is accurate as of July 14, 2017.

ISPFCU VISA PLATINUM PROGRAMS TERMS AND CONDITIONS The information about the costs of the card described is accurate as of July 14, 2017. ISPFCU VISA PLATINUM PROGRAMS TERMS AND CONDITIONS The information about the costs of the card described is accurate as of July 14, 2017. ANNUAL PERCENTAGE RATE (APR) Other APRs Platinum Elite: Wall Street

More information

Important -- To avoid delays in the processing of your documents, please review and follow the steps below.

Important -- To avoid delays in the processing of your documents, please review and follow the steps below. CLIENT DIRECTED SALE FORM Purchaser must provide the following to complete the transaction: o Signed dated Sale Form (page 3) with Purchaser's name, address, phone number, completed odometer, and email

More information

Grijalva Films, LLC DBA Rent Cine RENTAL FORMS PACKAGE

Grijalva Films, LLC DBA Rent Cine RENTAL FORMS PACKAGE DBA Rent Cine RENTAL FORMS PACKAGE Dear Grijalva Films, LLC Client, Thank you for your interest in becoming a new rental client. We ve designed the following forms package to conveniently provide you with

More information

ELECTRONIC FUND TRANSFERS AGREEMENT AND DISCLOSURE

ELECTRONIC FUND TRANSFERS AGREEMENT AND DISCLOSURE ELECTRONIC FUND TRANSFERS AGREEMENT AND DISCLOSURE This Electronic Fund Transfers Agreement and Disclosure is the contract which covers your and our rights and responsibilities concerning the electronic

More information

Legal Community Credit Union. Electronic Fund Transfers Agreement and Disclosure

Legal Community Credit Union. Electronic Fund Transfers Agreement and Disclosure Legal Community Credit Union Electronic Fund Transfers Agreement and Disclosure Table of Contents Electronic Fund Transfers Agreement and Disclosure (effective 10/13)... 2 EFT Services... 2 MasterCard

More information

VISA PLATINUM ELITE/VISA PLATINUM SELECT/VISA PLATINUM/VISA PLATINUM SECURE CONSUMER CREDIT CARD AGREEMENT

VISA PLATINUM ELITE/VISA PLATINUM SELECT/VISA PLATINUM/VISA PLATINUM SECURE CONSUMER CREDIT CARD AGREEMENT VISA PLATINUM ELITE/VISA PLATINUM SELECT/VISA PLATINUM/VISA PLATINUM SECURE CONSUMER CREDIT CARD AGREEMENT In this Agreement, Agreement means this Consumer Credit Card Agreement. Disclosure means the Credit

More information