Credit Application

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Or, if you prefer, you can fill out this PDF Version instead. Simply enter your information, print it out, and either fax it over or bring it in.

* indicates a required field

* Ownership

* Business Name

* Street Address

* City
* State

* Zip Code

* Telephone

* Fax

* Federal Tax ID

* Duns #

* Date Established

* Est. Annual Sales

* Is Company Tax Exempt?
(If yes, a copy of your Tax Exempt Form or Certificate of Resale MUST be submitted)

* Sales Contact

* A/P Contact

* Principle Officers

* Supplier/Vendor Reference 1

Supplier/Vendor Reference 2

Supplier/Vendor Reference 3

* Bank Reference 1

Bank Reference 2

Bank Reference 3

Invoices must be paid net 30 days from the billing date. In the event that CHUTES International must initiate collection proceedings to recover any portion, or all, of this amount, then the customer agrees to pay any collection costs incurred to collect the unpaid balance, including interest on the unpaid balance as allowed by state law and any attorney’s fees incurred. Any and all litigation will take place in Charles County, Maryland USA.

The undersigned as an inducement to grant credit warrants that the information submitted is true and correct. Undersigned does jointly and severally personally guarantees to pay and be responsible for all sums, balances and accounts due seller including interest, collection fees and/or attorney fees. Furthermore, this authorization allows CHUTES International to investigate the credit references listed above. We hereby authorize copies of this release to those who request it.

* For:

* By (Authorized Representative):

* Signature:
By typing your name in the above textbox, you agree that it is the electronic version of your signature.