Confidential Credit Application and Agreement (Business Only)

To apply for credit with BR Supply, Inc. fill out the form below, and push the Submit button. You will be contacted when your account is created and ready for use.

Business Applicant Information

Firm Or Business Name

Billing Address

City

State

Zip Code

County

Shipping Address (if different)

City

State

Zip Code

County

Phone

Fax

General Contact Name

Cell Phone

Accounts Payable Contact Name

Accounts Payable Phone

Email Address

Monthly Usage (approximate dollars per month)

Is this account non-taxable?

Yes

If this account is non-taxable, attach your sales tax exemption form here:

I prefer to fax, mail, or drop off my tax exemption form.

Do you have an EPA certification?

Yes

If you have an EPA certificate, please attach it here:

I prefer to fax, mail, or drop off a copy of my EPA certificate.

Primary Store Location

Sales Rep (if any):

Please list the full names, titles, and phone numbers of the business members and officers.

Member/Officer 1 Name

Member/Officer 1 Title

Member/Officer 1 Phone

Member/Officer 2 Name

Member/Officer 2 Title

Member/Officer 2 Phone

Member/Officer 3 Name

Member/Officer 3 Title

Member/Officer 3 Phone

Bank References:

Bank Contact Name

Bank Address

City

State

Zip Code

Phone

Credit References and Suppliers (please provide 4):

Reference 1 Name

Address

City

State

Zip Code

Phone

Fax

Reference 2 Name

Address

City

State

Zip Code

Phone

Fax

Reference 3 Name

Address

City

State

Zip Code

Phone

Fax

Reference 4 Name

Address

City

State

Zip Code

Phone

Fax

STANDARD TERMS and CONDITIONS of CREDIT SALES (SIGNING ACKNOWLEDGES YOU READ AND UNDERSTAND ALL CONDITIONS)

TERMS:

Remittance address: BR Supply, Inc., 3250 E Main Street, Humboldt TN 38343, (731) 784-1895. Please send all payments to this address.

Credit Terms are Net 10th. All invoices will be billed at the end of the month and due by the 10th of the following month. Account balances paid using credit cards may be subject to a 3% surcharge. All open account credit limits will be established entirely at BR Supply, Inc.’s discretion and shall be subject to change without notice. Past due accounts are subject to a service charge equal to 2% per month, but in no event higher than permitted by law. All monies collected will first be applied to service charges and the balance applied to the account. In addition to such late payment charges, any and all cost associated with collection of past due amounts, including but not limited to court cost and reasonable attorney’s fees, shall be added to the amount past due. BR Supply, Inc. reserves the right to place past due accounts on credit hold and/or cancel outstanding orders or pending shipments. It shall be an act of default hereunder if the customer: A. fails to pay a single statement or invoice when due; B. seeks the protection of state insolvency laws; C. files any type of petition of bankruptcy; D. allows his, her or its, inventory to be subject to non consensual lien or judgment lien; or E. commits any act which would diminish the security interest of BR Supply, Inc. in its collateral.

SALES TAX: Any tax, including but not limited to: sales and/or excise taxes on sales or use of the merchandise sold by BR Supply, Inc. must be paid by the customer and will be added to the amount due from each sale. BR Supply, Inc. will accept tax exemption certificates and exclude appropriate sales and use taxes from the invoices total provided that (1) the customer provided BR Supply, Inc. with a tax exemption certificate issued by the state that charges the particular tax in question (2) The customer purchase is to be used for the same purpose that the exemption certificate was granted by the state. (3) the exemption certificate has NOT expired. A request by the customer for an exemption from tax conditions the customers warranty that the exemption is justified, and the customer promises to notify BR Supply, Inc. against all claims, liabilities, interest, and penalties including reasonable attorney fees that result from any attempt by state to collect from BR Supply, Inc. any taxes which BR Supply, Inc. did not charge and receive from the customer. A copy of the signed and completed Tax Exemption Certificate MUST be on file with BR Supply, Inc. before any purchases are made.

INVOICES and STATEMENTS: Invoices will be given to customer at time of purchase. An extra copy can be e-mailed for your convenience. Monthly statements are emailed or mailed.

Do you want your open invoices emailed daily?

Please select how you wish to receive statements: Email Mail

Additional Information

ACKNOWLEDGMENT:

If this account is opened, be it understood that I acknowledge that I am responsible for the payment of any and all invoices that result from purchases that my representatives or I should make including payment guarantee on unsigned delivery invoices. The undersigned who is either a principal of the credit applicant or a sole proprietorship of the credit applicant, recognizing that his or her individual credit history may be a factor in the evaluation of the credit history of the applicant, hereby consents to and authorizes the use of a consumer credit report on the undersigned by the above named business credit grantor, from time to time as may be needed, in the credit evaluation process.

Typing my name below signifies my agreement to the above.

Principal Or Owner Signature

Social Security Number (this is encrypted for security when the form is submitted)

Today's Date

PERSONAL GUARANTEE:

In consideration of this agreement with BR Supply, Inc. and its successors to extend credit to us, we grant interest in full payment of all sums which are now due or which may become due, I, the undersigned, further agree that BR Supply, Inc. having granted credit may later refuse to do so, and that such refusal shall in no way affect guaranty.

Typing my name below signifies my agreement to the above.

Principal or Owner Signature

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