subject_line
Credit Application
Company Information
Applicant Name
*
Applicant Email
*
Applicant Company
*
If your company is tax-exempt, please send your tax exemption certificate to AR@essellc.com.
Company
*
Headquarters
Branch
Company Billing Address Line 1
*
Company Billing City
*
Company Billing State
*
Company Billing Zip
*
Company Shipping Address Line 1
*
Company Shipping City
*
Company Shipping State
*
Company Shippng Zip
*
Company County
*
Location
*
Inside city limits
Outside city limits
Company Phone
*
Company Fax
*
Requested Credit Limit
*
Trade References
Phone numbers need to be 10 digits ONLY with no special characters (i.e. 7706061539 NOT 770-606-1539).
Company 1
Company Name
*
Contact
*
Phone
*
Email
*
Company 2
Company Name
*
Contact
*
Phone
*
Email
*
Company 3
Company Name
Contact
Phone
Email
Company 4
Company Name
Contact
Phone
Email
Bank References
Company 1
Company Name
*
Contact
*
Phone
*
Email
*
Company 2
Company Name
Contact
Phone
Email
Company Details
Date Business Established
*
+
Date of Purchase if not Original Owner
+
Business Type
*
Corporation
LLC/LLP
Proprietorship
Other
If Other, please specify:
Incorporation Date
+
State of Incorporation:
Annual Sales Volume:
*
Company website:
*
DUNS#
*
Fed EIN:
*
Tax Exempt #:
Tax Jurisdiction:
*
Accounting Contacts
AP Contact
Name
*
Phone
*
Email
*
Purchasing Contact
Name
*
Phone
*
Email
*
Sales Tax Status
The undersigned certifies that all tanglible personal property to be purchased from Energy Systems Southeast, LLC will be exempt from the Sales Tax for:
State
*
City
*
County
*
for the following reason:
*
Said tangible personal property is purchased for Sales
Said tangible personal property will enter into and become an ingredient or component part of tangible personal property or products to be manufactured or compounded for sale by the undersigned
We hold a direct pay permit authorizing us to purchase taxable, tangible, personal property without prepayment of sales or use tax
If permit, Permit No.:
If such property or any portion thereof which is purchased pursuant to thus certificate is determined to be subject to such tax, it is agreed that such tax will be paid by the undersigned.
State Sales Tax Number
*
City Sales Tax Number
*
County Sales Tax Number
*
County Sales Tax Number
*
Authorizations and Signature
I, the applicant, understand and agree to meet Energy Systems Southeast's terms of sale, to pay any service charges assessed, and to pay reasonable attorney fees in the event of default.
I hereby authorize Energy Systems Southeast, LLC or its agents/assigns to verify or investigate any and all of the foregoing statements made in conjunction with an application for business funding/leasing verification. This includes but is not limited to my/our credit worthiness and financial responsibility in any way they may choose.
I/we grant authorize Energy Systems Southeast, LLC the right to procure any and all credit reports pertaining to any party listed on the application for business funding/leasing including but not limited to all principals of the applicant company.
The undersigned verifies that all information provided in each section of the Credit Application is current and accurate as of the date submitted.
Agreed and consented to by:
Print Name
*
Title
*
Signature of Authorized Purchaser
*
clear
Date Submitted
*
+
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