Leonard Brush - Account Application

Account Application

Type of Account Requested:

Your Name:

E-Mail:

Business Name:

City:

Phone:

Email:

Billing Address:

City:

State:

Zip:

Ship To Address:

City:

State:

Zip:

Contact People:
Purchasing/Buyer:	Phone:
Accounts Payable:	Phone:
	Fax:

Business Ownership:

Federal Tax ID #

Type of Business:

Years In Business:

Owners / Officers

Name:	Title:	Social Security #:
Address:	City:	State:	Zip:
Name:	Title:	Social Security #:
Address:	City:	State:	Zip:

Banking

Bank Name:	City:	State:
Phone:	Checking Account #:	Loan Account #:

Major Trade References

Supplier's Name:	Account #:	Phone:
Supplier's Name:	Account #:	Phone:
Supplier's Name:	Account #:	Phone:

I certify that the above information is correct and I authorize the creditors listed above to provide credit information to Leonard Brush & Chemical Co.

The undersigned purchaser agrees to pay. In the event it becomes necessary to place this account with an attorney for collection, Buyer agrees to pay, in addition to the principal amount therof with interest and other lawful charges. All costs and expenses of Collection including reasonable attorney's fees of 30%. All amounts over 30 days are subject to 1.5% monthly service charge.

Free delivery to the greater Louisville, KY area. There is a $50 minimum purchase for free delivery. If customer request under minimum order to be delivered, there will be a $10.00 fee added to order. Due to the high cost of fuel, a fuel surcharge may be added to delivered orders. Orders outside Louisville, KY Area are shipped F.O.B. Louisville, KY. USA Freight will be prepaid and freight charges will be added to invoice.

Return check fee is $20.00. All prices are United States Dollars.

Do you agree to the above terms?