INTERNATIONALACCOUNTANDCREDITAPPLICATION

 

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Date: PERSONCOMPLETINGAPPLICATIONPICKONE: EssendantCo EssendantIndustrialLLC HOWAPPLIED:Phone InPerson Fax/Mail

BusinessName:

DBA:

Phone: Fax: Emailaddress:

Dunn&Bradstreet(D&B#)(ifknown):

GeneralDescriptionofproductstobepurchased: BILLINGADDRESS

CompanyName:

CompanyAddress:

City: State/Province1: Zip/PostalCode: Country:

Phone: Fax: Emailaddress:

ContactName: USFREIGHTFORWARDERORDELIVERYADDRESS(REQUIRED)

CompanyName:

CompanyAddress:

City: State/Province1: Zip/PostalCode:

Phone: Fax: Emailaddress:

ContactName:

CUSTOMERSHIPTOADDRESS(FINALDESTINATION)

CompanyName:

CompanyAddress:

City: State/Province1: Zip/PostalCode: Country:

Phone: Fax: E‐mail: ContactName:

Doyouexport?Yes No Ifyes,whatcountries?

DoesyourcompanyhaveaU.S.affiliate?Yes No Ifyes,providefullname: Does the customer, including any subsidiaries and affiliates, engage in or expect to engage in activitywith SanctionedCountry2 in thefollowingmanner:

a. Physicallocations(offices,branches,operationsorjointventures),assetsorinvestments Yes No b. Buy,sellorotherwisedealinorfinanceproducts,merchandise,commoditiesorservices? Yes No c. Hasadirector,seniorofficeror10%orgreaterowner/shareholderwhoisa(1)citizen,resident

or(2)governmentalagency/authorityofaSanctionedCountry?Yes No

Webaddress:

TypeofBusiness: DateEstablished(CurrentOwner):

NoofEmployees: NoofLocations: Est.AnnualSales:

OWNERSHIP: SoleOwner Partnership Corporation Proprietorship LLC

                                                            1  PleaseprovidefullProvincename.Donotabbreviate. 2  SANCTIONEDCOUNTRIES:Cuba,Iran,Sudan,Syria,NorthKorea 

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PRIMARYCONTACTS:

Owner: (Name) (Phone#) (PercentageOwnership)

President: (Name) (Phone#) (PercentageOwnership)

VicePresident: (Name) (Phone#) (PercentageOwnership)

PurchasingAgent: (Name) (Phone#) (PercentageOwnership)REQUESTEDMODEOFPAYMENT: BankWireTransferonDemand OpenAccountTerms

Desiredcreditlimit:*Acurrentfinancialstatementmustbesubmittedinordertoqualifyforcreditapproval.

PERSON(S)RESPONSIBLEFORPAYMENTS

AP‐Contact/Phone

Contact/Phone

EmailAddress

ShippinginstructionsBackOrders Retain Cancel Doyourequiremonthlystatement: Yes No Acceptsubstitutions: Yes No Acceptpartialshipments: Yes No

CREDITINFORMATION

TRADEREFERENCES:(Namesuppliersofmajorproductsandservices)CompanyName: City: State: Zip: Phone: Fax: Contact: CompanyName: City: State: Zip: Phone: Fax: Contact:

CompanyName: City: State: Zip: Phone: Fax: Contact: BANKREFERENCE:Checking Loan Savings

BankName: City: State: Zip: Phone: Fax: Contact:

IfcreditisextendedI/Weagreetopayalldebtsincurredwiththetermsofsale.However,shouldthedebtbecomepastdue,I/Weexpresslyagree(subjecttostatutoryregulations)topayfinancechargesonthepastdueamountsattherateof1½%permonth(18%annualrate);providedthatnoprovisionofthisagreementrequiresorpermitsthecollectionoffinancechargesinexcessofthemaximumamountpermittedbylaw.I/Weexpresslyagreetopayreasonablecollectioncostsand/orattorney’sfeesincurredinconnectionwiththecollectionofthisaccount.Theapplicantsubmitstothenon‐exclusivejurisdictionofthecourtshavingsitusinthestateofIllinoisandintheUnitedStatesDistrictCourtfortheNorthernDistrictofIllinoisinanysuit,actionorproceedingarisingfromtheextensionofcreditorthesaleofgoodsbyEssendantCoorEssendantIndustrialLLCtotheapplicant for service of process, summons, notice or other document bymailwill be effective service of process for any suit, action or other proceedingbroughtinanysuchcourt.Theapplicantirrevocablywaivesandagreesnottopleadorclaiminanysuchsuit,actionorproceedingbroughtinanysuchcourtthatithasbeenbroughtinaninconvenientforum.

11/16/2015Officer/PrincipalSignature(Authorizedsigneronbankaccount) PrintName Date

Ifrequired,aretheprincipalownerswillingtosignapersonalguarantee? Yes No

Allaccountapplicationsmustbecompletedinfullandlegiblefordepartmentalinputoritwillnotbeprocessed.TheinformationintheAccountandCreditApplicationissubmittedinconfidence.

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ADDITIONALACCOUNTINFORMATION

 

HowdidyoufindoutaboutEssendant(whoreferred/whatcompany):

Willtheitemsbeingpurchasedbeusedforanythingotherthanresale? Yes No Ifyes,pleaseexplain:

 

 DESCRIBEYOURBUSINESSLOCATION(S):

Doyouhave: WarehouseorDistributionCenter? Showroomorretailsite? Deliverytrucks? Otherdistributioninfrastructure?OR

isyourbusinessoperatedas: WarehouseorDistributionCenter?

 

PleasereviewourTermsandConditionslocatedonourwebsitewww.orsnasco.com.Returnthecompletedformviaemailtonewaccounts@orsnasco.comorfax(918)781‐5343

IagreetotheTermsandConditions(Pleaseinitial)

                                                            3  PleaseprovidefullProvincename.Donotabbreviate. 

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STATEMENT OF FINANCIAL CONDITION OF AS OF

CASH ACCOUNTS PAYALE

ACCOUNTS RECEIVEABLE SHORT TERM BANK DEBT

INVENTORY ACCRUALS

CURRENT ASSETS CURRENT LIABILITIES 

FIXED ASSETS LONG TERM BANK DEBT

TOTAL ASSETS OTHER LONG TERM DEBT

TOTAL DEBT

 

NET SALES NET WORTH

COST OF SALES FOR MONTHS

GROSS PROFIT

NET INCOME

BY

TITLE

UNIFORM SALES AND USE TAX CERTIFICATE—MULTIJURISDICTION

The below-listed states have indicated that this form of certificate is acceptable. The issuer and the recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change from time to time.

Issued to Seller:

Address:

Enter all bill account number(s): Federal Employer ID Number I certify that:

Legal Name of Company: is engaged as a registered: Wholesaler

DBA Name: Retailer

Manufacturer

Address Seller (California)

Lessor Exporter (Country) Other

and is registered with the below-listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product or service1 to be resold, leased, or rented in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following: Description of Business: General description of tangible property or taxable services to be purchased from the seller: Resale Business Products/Supplies _______________________________________________________________________________________________________________

Separate forms are required for FL, IN, LA, MA, MS, NY, VA, WV, and WY.

STATE State Registration, Seller’s Permit, STATE State Registration, Seller’s Permit, or ID number of Purchaser or ID number of Purchaser

AL MS Attach MS Sales Tax Permit

AR NE

AZ NV

CA NJ

CO NM

CT NC

DC ND

FL Attach Florida DR-13 OH

GA OK

HI PA

ID RI

IL SC

IA SD

KS TN

KY TX

ME UT

MD VT

MI WA

MN WI

MO ____________________________________

For Buyers with locations in states that do not require sales tax registration, please check the appropriate box(es):

AK DE MT NH OR I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be a part of each order, which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state.

Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter. Authorized Signature:

(Owner, Partner or Corporate Officer)

Title:

Date: