Credit Application

General Information:

Full Name:

Trade Name:

Legal Name of Parent Company:

Address:

City:

State:

Zip Code:

Contact:

Title:

Business Phone:

Fax:

Email:

Dun & Bradstreet Number:

Credit Limit Requested:

Years in Business:

Ever Filed Bankruptcy:

Is this a Branch Office:

Account Number:

Legal Structure:

Type of Business:

Principals or Officers:

1.) Name:

Title:

Home Address:

City:

State:

Zipcode:

Home Phone:

Email:

Additional Principals:

Bank Reference:

Principal Bank:

Account Number:

Address:

City:

State:

Zip Code:

Bank Officer:

Phone:

Fax:

Trade References:

1.) Name:

Account Number:

Address:

City:

State:

Contact:

Phone:

Fax:

2.) Name:

Account Number:

Address:

City:

State:

Contact:

Phone:

Fax:

3.) Name:

Account Number:

Address:

City:

State:

Contact:

Fax:

Phone:

Financial Statements:

Terms and Conditions

Liquid Environmental Solutions is hereby authorized to inquire and receive any and all information about our banking relationships, trade references and credit information. A photocopy or facsimile copy of this authorization shall be valid as an original thereof. The undersigned, being principal director of the aforesaid business, individually, jointly and severally guarantee the payment of any and all future obligations of said business which may be owing to Liquid Environmental Solutions upon demand, including reasonable attorney's fees and all costs, among other expenses, incurred by Liquid Environmental Solutions in collecting indebtedness of the aforesaid business. In the event of a default in payment, we authorize Liquid Environmental Solutions to charge the maximum rate of interest allowed by law. This is a continuing guarantee and may be revoked only in writing by delivery to Liquid Environmental Solutions, at 7651 Esters Blvd Ste 200 Irving, TX 75063, via certified mail, but such revocation will be effective only as to transactions entered into after Liquid Environmental Solutions' receipt of the notice of revocation. Client agrees that venue for any suit arising out of this agreement shall be, in addition to any place allowed by law, Dallas County, Texas. Should it be necessary for us to employ an attorney or collection agency to remedy breach of this agreement to collect any amount due. Client agrees to pay our reasonable attorney's fees, collection costs and expenses. A photocopy or facsimile copy of this completed account application is admissible to prove existence of the original. Payment terms for Liquid Environmental Solutions and its affiliated companies are Net 20.

By Clicking on the submit button below, the applicant states that it has read, understands and agrees to the terms and conditions set forth herein and further certifies that all of the information contained in the application and attachments is true and correct to the best of their information, knowledge, and belief, and further certifies that it is authorized to execute this application on behalf of applicant.

Name:

Title:

Best Contact Phone #: