Credit Application

Fill out form below or download form here and FAX back to (757) 460-2699.

Credit Application

Date *

Applicant's Name *

Business Name *

Business Address *

Phone *

Email *

Type of Busines *

Years in Business *

Is Applicant *

Individual

Proprietorship

Corporation

Partnership

Customer Federal ID# *

Tax Exempt *

Yes

Tax Exempt #

PO Number Required? *

Yes

Credit References:

Please fill this section out in full

Bank Information

Bank Name *

Bank Address *

Contact Name *

Phone *

Trade References

1.

Name *

Address *

Phone *

2.

Name

Address

Phone

3.

Name

Address

Phone

4.

Name

Address

Phone

Amount *
Credit Amount applied for:PER MONTH

Principle Name *

Address *

Phone *

Person(s) Authorized to Request Service for this Customer

1. *

2.

3.

4.

I / We hereby authorize Mr Plumber to obtain any credit or other information from whatever sources they may consider appropriate in order to establish and maintain a credit account in my/our name. I / We understand that all invoices are due and payable fifteen (15) days from date of invoice and personally agree to pay 1.5 % interest per month (18% per annum) or as otherwise specified from time to time on the invoices rendered, on amounts overdue, in addition to any collection, court and legal costs that may be incurred in order to collect amounts that may become delinquent hereunder in the amount of 33%. All returned checks are subject to $50 return fee.

Please Check Box *

I Agree

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