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Business Contact Information:

Your Name

Person filling out this application.

Company Name

Phone

Fax

Email

Registered Company Street Address

City

State

Zip

Business Type

Date Business Commenced

Business and Credit Information

Primary Business Address:

Please give the street, city, state, and zip code of the business' physical location. (If different from above)

How long has the business been at the above address?

Business Phone

Business Fax

Business Main Email

Bank Name & Address

Please enter the complete address: street, city, state, and zip code.

1. Type of Account

1. Account Number

2. Type of Account

2. Account Number

3. Type of Account

3. Account Number

Business / Trade References:

1. Company Name

1. Complete Address

Please include the references complete address; street address, city, state, and zip code.

1. Phone

1. Fax

1. Account Type

2. Company Name

2. Complete Address

Please include the references complete address; street address, city, state, and zip code.

2. Phone

2. Fax

2. Account Type

3. Company Name

3. Complete Address

Please include the references complete address; street address, city, state, and zip code.

3. Phone

3. Fax

3. Account Type

Signatures / Agreement:

1. All invoices are to be paid 30 days from the date of the invoice. On balances over 30 days a finance charge of 1 1/2% per month (18% per annum) will be charged.
2. Claims arising from invoices must be made within seven working days.
3. By submitting this application, you authorize Robert Greene, Inc. to make inquiries into the banking and business/trade references that you have supplied.
4. Attest that you have reviewed and agree to the Retail Credit Agreement and the Federal Truth in Lending Act Information with links at the top of this page.

Applicant Signature

Please type your full name - as your electronic signature

Title at the Company:

Your form has been submitted. Thank You!