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| BLOCK READY MIX
GROUP |
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| P.O. BOX
280
Bettendorf, IA
52722 |
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| General Office
(563) 823-2080 Fax (563)
823-2071 |
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| Ready Mix (563)
884-4117
Fax (563) 884-4037 |
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| CREDIT APPLICATION |
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DATE: |
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| BUSINESS INFORMATION |
DESCRIPTION OF BUSINESS |
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| Name of Business (Applicant) |
No. of Employees |
Annual Sales |
Type of Business |
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| Legal (If Different) |
Web Site |
Credit Requested |
In Business Since |
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| Billing Address |
BUSINESS STRUCTURE (circle one)
Corporation
Partnership
Proprietorship |
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State |
Zip |
Division/Subsidiary?
Y / N
If Yes, Name of Parent Company |
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| Ship to Address (If Different) |
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Parent in Business for
years |
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State |
Zip |
SSN or FEIN |
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| Phone |
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Fax |
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Tax Exempt on
Purchases? Y / N (If Y, Attach Certificate) |
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Monthly Statement
Required? Y / N |
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| OWNERS, OFFICERS, AND CONTACTS |
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| Name of Principal Owner |
Address |
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Telephone |
E-mail |
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| Company President |
Address |
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Telephone |
E-mail |
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| Accounts Payable Contact |
Address |
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Telephone |
E-mail |
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| Purchase Order Contact |
Address |
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Telephone |
E-mail |
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| TRADE REFERENCES |
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| Name |
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Address (Street,
City, State, Zip) |
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Contact Name |
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| Name |
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Address (Street,
City, State, Zip) |
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Contact Name |
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Address (Street,
City, State, Zip) |
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Contact Name |
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| BANK INFORMATION |
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| Name |
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Address (Street,
City, State, Zip) |
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Contact Name |
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| TERMS & CONDITIONS |
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| I/we authorize W.G. Block Co. to obtain such
information regarding my credit rating, permitted by law, for this Credit
Application or for future Credit applications, and to retain this data on
file. The undersigned further
agrees, should credit be extended to the company, or myself individually,
payments will be made in accordance with the terms set forth on invoices
and shall be due to W.G. Block Co. at the remit to address listed on
invoices. Past due amounts,
30 days or over are subject to a finance charge of 1.5% per month (18% per
annum). Should the service of
an agency or an attorney be necessary to collect amounts outstanding, I/we
agree to pay all costs of such collection including reasonable attorney
fees. Any returned checks are
subject to a $20 returned check fee. |
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| By: Signature of Officer or Authorized Representative |
Title |
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