APPLICATION
FOR COD ACCEPTANCE

(FORM MUST BE COMPLETE FOR PROCESSING)
   
Store Name:
Address:
City:

State/Province:
Zip/Postal Code:
Owner's Name:
Business Phone:

Fax #
Owner's Home Address:
Owner's Home Phone:
VA State Resale #
# of years in business:
This location is a: Residence Business
   
Bank Name:
Account #:
Bank Address:
Telephone #:
Are you rated by Dun & Bradstreet? Yes No
D & B #:
Rating:
How many years have you owned this business?
 

Please list 4 trade references from which you purchase
terms COD.
Company:
Address:
City:
State:
Zip:
Telephone #:
Account #:
   
Company:
Address:
City:
State:
Zip:
Telephone #:
Account #:
   
Company:
Address:
City:
State:
Zip:
Telephone #:
Account #:
   
Company:
Address:
City:
State:
Zip:
Telephone #:
Account #:
 
I (We) authorize E&R Sales Inc. to contact my bank for a reference.

I (We) agree to the TERMS and conditions of E & R Sales, Inc., requiring payment within the specified agreed to Terms of Invoice.

I (We) also agree to pay a 2% per month Finance Charge on all unpaid overdue balances. If my account should become delinquent and must be turned over for collection, I also agree to reimburse
E & R Sales, for all collection and legal fees related to this collection action.
 
Authorized Signature
Title:
Date:
 
 

E & R Sales
4800 Market Square Lane
Midlothian, VA 23112
1-800-234-7474
Fax: 804-744-5125