Credit Application



CREDIT APPLICATION

|[pic] | | Phone: 847-468-8082 |

| |D&S Communications, Inc |FAX: 847-468-8086 |

| |1355 N. McLean Blvd. |Email: cmostowski@ |

| |Elgin, IL 60123 | |

|Customer |

|Name: |DBA: |

|Address: |

|City: |State: |Zip Code: |

|Contact: |Telephone: |

|Fax: |Email: |

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|A/P Contact Name: |Email: |

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|Key Officers, Partners or Owners |

|Name: |Title: |SS#: |

|Home Address, City, State and Zip |

|Name: |Title: |SS#: |

|Home Address, City, State and Zip: |

|CREDIT INFORMATION |

|TYPE OF BUSINESS Corporation Partnership Proprietorship |

|Years in Business: |Annual Sales Dollars: |

|Nature of Business: |Number of Employees: |

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|If company is a reseller please provide Reseller Certificate # |Tax Exemption # |

|Bank Reference |

|Bank |Address |

|Officer Name |Telephone |

|Account # | |

|Trade Reference |

|Company / Contact |Telephone Fax# |

|Company / Contact |Telephone Fax# |

|Company / Contact |Telephone Fax# |

Terms and Conditions

I/We certify that all information is true and complete. This request is for a D&S Communications, Inc. account. I/We authorize D&S Communications, Inc. to obtain further information concerning credit and financial conditions of the corporation, principal owners, proprietors or partners, and to exchange information with other grantors. I/We agree to pay the amount invoiced in full upon the due date of invoice. In the event D&S Communications, Inc. extends credit to the applicant, the applicant agees that D&S Communications, Inc. may assess interest and services charges on Purchaser’s outstanding account balance at a rate of 1.5% per month (18%) per annum. The Puchaser further agrees to pay any and all costs of collection, including but not limited to attorney’s fees which shall include attorney’s fee on appeal in the event applicant’s account is turned over to an attorney. Each Owner/Officer is equally and/ or soley liable for all debts incurred by the corporation, principal owners, proprietors, or partners to D&S Communications, Inc. This request to establish an account with D&S Communications, Inc. shall include the approval to debit the following credit card account in the event Purchaser’s account is delinquent by the approved term date. Purchaser further acknowledges that Purchaser shall not dispute any and all charges in accordance to D&S Communications, Inc. debiting Purchaser’s Credit Card account. In the event Purchaser selects to pay any and all outstanding invoices by the means of Credit Card, the Purchaser shall be responsible for an additional (3%) percent handling fee in accordance to the total amount being debited from Purchaser Credit Card Account. D&S Communications, Inc. shall assess a seventy-five dollar ($75) for any and all insufficient checks returned from Purchaser’s financial institution.

Credit Card Information is REQUIRED for submittal of the Credit Application.

Credit Card: ______ American Express _______ Mastercard __________ Visa ___________ Discover

Credit Card No. _____________________________________________ Exp: ___________________ Security Code ________

Name on Credit Card: ______________________________________________

Billing Address for Credit Card: ______________________________________________________________________________

City ___________________ State: ___________ Zip Code: _______________ Telephone No.__________________________

This credit application shall reference an established Credit Card fir credit consideration. It is the Purchaser’s responsibility to contact D&S Communications, Inc to retain current information. In the event the Credit Card information changes or expires at D&S Communications, Inc. sole discretion, credit terms shall be terminated immediately.

Authorization:

By signature below I/we authorize D & S Communications, Inc. to contact the references listed above. I/we also authorize the references listed above to release information about our history to D & S Communications. Applicant accepts and agrees to be bound by the Terms and Conditions of this Credit Application

SIGNATURE REQUIRED BY: TWO OFFICERS(if corporation), PRINCIPAL OWNER, PROPRIETOR OR PARTNER

|SIGNATURE: ________________________________ |

|TITLE: ________________________________ |

|DATE: ________________________________ |

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|SIGNATURE: ________________________________ |

|TITLE: ________________________________ |

|DATE: ________________________________ |

|Credit Department Only | |

|Approved Disapproved $Amount | |

|By | |

|Date | |

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