APPLICATION
FOR NET ACCEPTANCE

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

State/Province:
Zip/Postal Code:
Owner's Name:
Business Phone:
Business Fax:
Owner's Home Address:
Owner's Home Phone:
State Resale #
This location is a: Residence Business
   
Bank Name:
Account #:
Bank Address:
Telephone #:
Are you rated by Dun & Bradstreet? Yes No
D & B #:
Date business opened
(month & year)
 

Please list 6 trade references from which you purchase
with NET terms.
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 #:
 
Company:
Address:
City:
State:
Zip:
Telephone #:
Account #:
 
Company:
Address:
City:
State:
Zip:
Telephone #:
Account #:
 

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