Credit Application

Name Of Company *

Company Website

Name *

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Last

Name of person filling out form

Email *

Accounts Payable Contact *

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Last

Accounts Payable Email *

Preferred Method of Delivery for Invoices and/or Statements

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Company Name #1 *

Contact Name *

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Last

Email *

Company Name #2 *

Contact Name *

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Last

Email *

Company Name #3 *

Name *

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Last

Email *

The undersigned applicant does hereby certify that the information given is correct and complete, and further agrees to permit Rolltex, Inc. to use this information to obtain additional required credit information. If, after reviewing all credit information, this application is approved, it is agreed and understood by the undersigned and Rolltex, Inc. that all purchases made on an open account will be PAID IN FULL within 30 days from the date of invoice. Any account which has an unpaid balance at the end of 45 days in which payment is due, will be ASSESSED A FINANCE CHARGE on the unpaid portion at the applicable monthly rate (1.5% per month which corresponds to an 18% annual percentage rate) until such time the account has been brought current. In the event of suit to collect, any amount due on said account and all costs of collection, including (without limitation) attorney's fees, will be charged. The undersigned agrees to assume the full responsibility of charge purchases made on the account by any of the application's employees listed above, or as from time to lime revised. In consideration of the credit extended hereunder, the undersigned (who if two or more in number shall jointly and severally be liable) hereby unconditionally and personally guarantee(s) full payment of the account. Authorized returns will be credited as soon as the product is received in our warehouse - less a 15% restocking fee. In the case of special orders, a credit will only be granted if we are able to return the merchandise to the supplier. If the item is not returnable, you will be responsible for the original invoice on the item, payable within our terms as stated above. *

Signature Required

Date (XX/XX/XXXX) *