Welcome to our Online Credit Application

Please fill out every part and then hit Submit

ACCOUNT TO BE GIVEN CREDIT

Name 

Address

City/State/Zip

Bus. Telephone

Federal ID no.

PLEASE PUT AN "X" IN ONE OF THE BOXES

Corporation 

Trust

Partnership

Proprietorship

PRINCIPALS

Name

Home Address

City/State/Zip

Soc. Sec. No.

Name

Home Address

City/State/Zip

Soc. Sec. No

BANK REFERENCE

Name of Bank

Address

Account No.

Telephone

TRADE REFERENCES

Name

Address

City/State/Zip

Telephone 

Name

Address

City/State/Zip

Telephone

Name

Address

City/State/Zip

Telephone

Name

Address

City/State/Zip

Telephone

I hereby certify that all information supplied in this application is correct and is given for the purpose of obtaining credit. in consideration of the jack young company. Inc. Selling to me or my agents, I agree to the following Terms:

(1) To pay our account in full within 30 days of the date of each monthly statement.

(2) To pay service charges for late payment, computed at an annual rate of 18%

(3) To pay all reasonable charges for collection, including attorney's fees, if our account is placed for collection.

(4) When I click send I understand I authorize any credit investigation needed for action on this credit application, and authorize the above-named bank to release information about our account in response to credit inquiries by the Jack Young Company, Inc.

YOUR NAME IN FULL