* REQUIRED FIELDS
*Business Name:

*Trade Name or DBA:

*Mailing Address:

*Contact Phone #: With area code. Contact Fax #: With area code.
Contact eMail:

Shipping Address:If different from Mailing address.

*Year Started: Tax Exempt #:
Please send appropreate documentation to support tax exempt status.

*Description of Business:

*Type of Business: Corporation Partnership Sole Proprietor

*Anticipated monthly volume: *Amount of credit requested:

*Do you use purchase orders?: Yes No

*Person responsible for accounts payable:
*Has applicant or any principal ever filed a voluntary petition in bankruptcy?
Yes No Year

*Has a tax lien been filed against applicant or principle within the last six months?
Yes No

Information on Officers / Owners
*Name:

*Address:

Home Phone #: With area code. Contact Fax #: With area code.
Social Security #: Title:

Name:

Address:

Home Phone #: With area code. Contact Fax #: With area code.
Social Security #: Title:

Name:

Address:

Home Phone #: With area code. Contact Fax #: With area code.
Social Security #: Title:

*Property Information
Owned: Year Purchased: Value: Morgage Amount:
Rented: Lease Expires: Landlord:

Banking Information

*Bank Name:
*Checking Acct. #: *Savings Acct. #:
*Address:

*Account Officer:

Trade References
*Name:

*Address:

*Phone #: With area code. Fax #: With area code.
*Amount Owing:

*Name:

*Address:

*Phone #: With area code. Fax #: With area code.
*Amount Owing:

*Name:
*Address:

*Phone #: With area code. Fax #: With area code.
*Amount Owing:

Conditions of Sale

In Consideration of A.C.T Lighting, Inc. extending credit to the applicant, the applicant agrees to pay for all items delivered to, or at the request of, the applicant in accordance with the terms of the invoice: Any invoice unpaid on the last day of the month in which it is due will be subject to a 1.5% monthly service charge, and an aditional 1.5% service charge (annual percentage rate 18%) will be due every thirty (30) days thereafter. A waiver of any one or more service charge(s) shall not be deemed to be a waiver of any future service charge(s). The applicant further agrees that with regard to such service charges, the applicant and A.C.T Lighting, Inc. are parties to a written contract. Should it become necessary to place the account with a collection agency or attorney, the applicant agrees to pay all collection costs and attorney fees in addition to the sums due.
No returns without prior authorization and an RMA number. A 20% restocking fee may be assessed on returned merchandise.The applicant, in signing this application, also authorizes the above listed banking and trade references to respond to credit inquiries regarding the applicant's account.

*I have read and understood the Conditions of sale





Signed:______________________________________ Date:___________
Not required for electronic submission.
june.22.mmvi