Credit Application Online Form

URL
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R&D Marketing, LLC Credit Application
P.O. Box 3352 Tupelo, MS 38803 Phone: (662) 620-2828 Fax: (662) 620-1116
Business Name:*
Trade Name:*
Phone Number:*
Fax Number:*
D&B Duns#:*
Shipping Address:*
Street Address City State ZIP Code
Billing Address:*
Street Address City State ZIP Code
Accounts Payable Contact:*
A/P Email Address:*
A/P Phone Number:*
A/P Fax Number:*
Type of Business (Trader, Wholesaler, Distributor, etc.):*
Year Established:*
Form of Business:*
- Sole Proprietorship
- Partnership
- Corp.
- LLC
State of Incorporation:*
Fiscal Year End:*
Number of Employees:*
Premises:*
- Owned
- Leased
Lease Expiration Date:
If leased, Owners Name & Address:
Name(s) of Owner, Officers, Partners:
Name:*
First Last
Title:*
Spouse's Name:*
First Last
Title:*
Address*
Street Address City State ZIP Code
Home Phone:
Cell Phone:*
Email:*
Name:*
First Last
Title:*
Spouse's Name:*
First Last
Title:*
Address*
Street Address City State ZIP Code
Home Phone:
Cell Phone:*
Email:*
Bank References:
Bank Name:*
Bank Contact:*
Address:*
Street Address City State ZIP Code
Phone Number:*
Email Address:*
Account Number:*
Fax Number:*

Trade References:
Company:*
Address*
Street Address City State ZIP Code
Contact Name:*
Email Address:*
Phone:*
Fax:*
Company:*
Address*
Street Address City State ZIP Code
Contact Name:*
Email Address:*
Phone:*
Fax:*
Company:*
Address*
Street Address City State ZIP Code
Contact Name:*
Email Address:*
Phone:*
Fax:*
Do you have any judgements against you?*
- Yes
- No
Have you ever been involved in bankruptcy?*
- Yes
- No
Do you have Accounts Receivable Insurance?*
- Yes
- No
Agreement:
I, the undersigned, certify that I am authorized to disclose information on behalf of the applicant and that all information given is true and correct. I also understand and agree to adhere to the credit terms set forth by R&D Marketing LLC. Note: Terms of sale are net 14 days from receipt of product.
Signature of Guarantor:*
Full Name:*
Title:*
Date:*
MM slash DD slash YYYY
Individual Personal Guarantee:
I, on behalf of the above-named business, hereby personally guarantee to R&D MARKETING, LLC., payment of any obligation of above-named business and agree to bind myself to pay R&D MARKETING LLC. On demand any sum which may become due if above-named business fails to pay services received from R&D MARKETING LLC.
Signature of Guarantor:*
Name:*
Title:*
Date:*
MM slash DD slash YYYY

R&D Marketing, LLC Credit Application