Credit Application
( Adobe Acrobat version)

Please complete these fields, then click "Print Form" at the bottom of this page.

FIRM
Company Name
dba
Type of Business			Individual Corporation Partnership
Billing Address
City			State	Zip
Shipping Address
City			State	Zip
Contact Person
Phone			Fax
Email Address
Accounts Payable
Phone			Fax
Email Address
BANK REFERENCE
Name
City			State	Zip
Phone			Fax
Account #			Branch
TRADE REFERENCES
1.	Name
City			State	Zip
Phone			Fax
2.	Name
City			State	Zip
Phone			Fax
3.	Name
City			State	Zip
Phone			Fax
4.	Name
City			State	Zip
Phone			Fax
TERMS
A.	Full payment of invoice is due no later than 30 days from the date on invoice. Amounts overdue (net 30) will be subject to a late payment charge of 1.5% per month.
B.	Applicant understands that LRI will make our usual credit investigation and authorizes applicant's bank to release information which may include consumer and/or commercial credit report as needed by LRI.
C.	Should it become necessary to assign the account balance to a licensed collection agency or attorney for legal action, all subsequent collection charges and legal fees shall be paid by the applicant.
D.	The undersigned agrees that all credit extended by LRI, shall be deemed subject to the terms agreed herein, and all invoices are payable and due.