Credit Application - Crown Eyewear

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Crown Eyewear Credit Application

Credit Aplication

Direct Billing

yes

no

Buying Group Name:

Buying Group A/C #:

Business Information

Business Name: (DBA)

Federal Tax ID:

Corporation name:

Date Established:

Tax Exempt?

yes

no

If Yes, copy of exemption form must be attached

Billing Address:

City/State:

Zip Code:

Shipping Address: (If different):

City/State:

Zip Code

Email:

Fax:

Principal’s Name:

Co-Owner Name: (If Any)

Principal’s Home Address:

SSN: (Optional)

City/State:

Zip Code:

Circle one:

Propretorship

Partnership

Corporation

LLC

Nonprofit Organization

Type of Business: (Check One)

Retail

Optical

Bank Reference

Bank Account Name:

A/C #:

Bank Name:

City/State:

Zip Code:

Phone:

Fax:

Email:

Trade Reference

Company Name:

A/C #:

City/State:

Phone:

Fax:

Email:

Company Name:

A/C #:

City/State:

Phone:

Fax:

Email:

Company Name:

A/C #:

City/State:

Phone:

Fax:

Email:

Name of Crown Eyewear representative who gave you this form:

Terms and Conditions: I agree to the terms of conditions listed on the second page and certify that all statements in application are true and complete and are made for the purpose of obtaining credit, which gives Crown Eyewear the right to contact references listed.

I Agree

Print Name:

Signature:

Date:

Personal Guaranty: The undersigned guarantor shall be liable for the principle owed and if the debt is placed with an attorney and/or collection agency, all fees associated with further collection efforts shall be added to the balance owed when allowed by law.

Print Name:

Signature:

Date:

Terms & Conditions*

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