Water Safety Credit Application Form

Thank you for your interest in our company. Please read and have the owner sign the statement below. Please provide 4 references with which you have established open terms, and who will release credit information. This will speed up the processing of your application. Upon approval, your terms will be determined. We look forward to working with you.

If you would prefer to download, fill out and fax the credit application to us, please click here.

*Required Fields

Company Information:

Business Name:
*
Owner's Name:
*
Address:
*
City: * State: * Postal Code: *
Telephone: * Fax: *
Type of Business Entity: *
Federal Tax I.D # or Social Security #:
*
Years in Business:
*
Email Address:

Financial Information:

Bank:
*
Contact:
*
Account #:
*
Bank Address:
*
City: * State: * Postal Code: *
Telephone: * Fax: *
Email Address:

Trade References:

*Please provide at least four references along with a contact person, phone, and/or email.
We primarily do our credit checks via fax.*

1. Company Name:
*
Contact:
*
Account #:
*
Telephone: * Fax: *
Email contact (if available):

2. Company Name:
*
Contact:
*
Account #:
*
Telephone: * Fax: *
Email contact (if available):

3. Company Name:
*
Contact:
*
Account #:
*
Telephone: * Fax: *
Email contact (if available):

4. Company Name:
*
Contact:
*
Account #:
*
Telephone: * Fax: *
Email contact (if available):

Authorization

I hereby apply for credit and certify the above information is correct. I understand the terms are net 30 ROG and agree to honor these if credit is extended. Should default occur I understand that we will be liable for the invoice amount as well as the highes amount of interest allowed by law, not to exceed 1.5% per month (18% per annum) and I, undersigned, state that I have full power of attorney to sign for this company, partnership, or corporation.

Owner's Signature:
*
Address:
*
Contact Telephone:
*

Authorization to Release Bank Information:

Company Name:
*
Federal Tax I.D #: *
BankName: *
Attn: *
Account Number: *
Bank Address:
*
City: * State: * Postal Code: *
Telephone: * Fax Number: *

To the Credit Department of our Bank:

You are hereby authorized to release all relevant information concerning our account to Water Safety Products, Inc. at 2330 Commerce Park Dr. NE Ste. 4 Palm Bay FL 32905 for the purposes of a credit verification.

Sincerely,

Print Name & Title:
*