DEY DISTRIBUTING: Application for Credit Account Form

Application for Credit Account

Company Name________________________________________________________

Street ________________________________________________________________

City _______________________ State ______________ Zip__________________

Owner ____________________ Phone (.....)_____________________________

Sales Tax No._______________ Fax (.....) ______________________________

We must have your tax certificate on file or bill you tax. (Tax certificate form attatched below.)

References (Include one bank reference with account number please)

1.Name _______________________________________________________________
   Address _____________________________________________________________
   Phone (___)________________________Acct No.___________________________

2.Name _______________________________________________________________
   Address _____________________________________________________________
   Phone (___)________________________Acct No.___________________________

3.Name _______________________________________________________________
   Address _____________________________________________________________
   Phone (___)________________________Acct No.___________________________

Type of Business ______________________________________________________

Do you use purchase order numbers___________________

Monthly estimate of purchases? _______________________

Do you anticipate doing warranty work? ________________

Do you use more than one shipping address? ____________
      ^{If yes, please list addresses on the back of this form}
Terms:
Failure to meet payment terms may cause future orders to be shipped on a COD basis. Applicant's signature attests financial responsibility in accordance with our stated terms.
Finance charges, legal fees, collection and court costs involved in collecting past due
charges will be the responsibility of the principals/officers/owners of the company
applying for credit.
Net 15th prox. 1½% service charge on past due accounts. Minimum billing $10.00

Date _______________________ Name______________________________

Title________________________ Signature___________________________
^{Must be signature of authorized owner/officer}

Multi Jurisdictional Uniform Sales & Use Tax Certificate

Issued to Seller ____________________________________________

Address__________________________________________________

_________________________________________________________

I certify that ________________________________ is engaged as a registered

___Wholesaler ___ Retailer ___ Manufacturer located at:

Address_____________________________________________________

City_______________________State____________Zip____________

and is registered with the below listed states within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, or components of a product to be sold, leased or rented in the course of business. We are in the business of wholesaling, retailing, manufacturing or leasing:

Description of Business ______________________________________________________

Description of products to be purchased__________________________________________

Exemption Certificate Information:

State
________

Exemption Certificate No.
_________________________

I further certify that any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due to the proper taxing authority when state law provides or informs the seller for added tax. This certificate shall be a part of each order which we may hereafter give to you and valid until cancelled by us in writing or revoked by city or state.

Under penalties of perjury, I swear or affirm that the information on this form is true and correct .

Signature_________________________Date_____________________________

_{Complete this form and send it to: Dey Distributing 1401 Willow Lake Blvd. Vadnais Heights, MN 55110 Fax: 800-728-3391}		_{Maintained by}^{mailto:webmaster}

Multi Jurisdictional Uniform Sales & Use Tax Certificate Issued to Seller ____________________________________________ Address__________________________________________________ _________________________________________________________ I certify that ________________________________ is engaged as a registered ___Wholesaler ___ Retailer ___ Manufacturer located at: Address_____________________________________________________ City_______________________State____________Zip____________ and is registered with the below listed states within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, or components of a product to be sold, leased or rented in the course of business. We are in the business of wholesaling, retailing, manufacturing or leasing: Description of Business ______________________________________________________ Description of products to be purchased__________________________________________

Exemption Certificate Information:
State ________		Exemption Certificate No. _________________________

I further certify that any property so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due to the proper taxing authority when state law provides or informs the seller for added tax. This certificate shall be a part of each order which we may hereafter give to you and valid until cancelled by us in writing or revoked by city or state. Under penalties of perjury, I swear or affirm that the information on this form is true and correct . Signature_________________________Date_____________________________

Application for Credit Account

Complete this form and send it to: Dey Distributing 1401 Willow Lake Blvd. Vadnais Heights, MN 55110 Fax: 800-728-3391

_{Complete this form and send it to:

Dey Distributing

1401 Willow Lake Blvd.

Vadnais Heights, MN 55110

Fax: 800-728-3391}