PLEASE NOTE:
We must have an application
on file even if you aro
requoSting CASH terms.
All  information must be
completed.

# <empty>
DATE <empty> / <empty> / <empty>
REP NAME: <empty>
REQUESTED TERMS:
N-30 <empty>
Prepaid <empty>

Telephone (800) 274-7730 • FAX (510) 236-0561
info@palecek.com

## CREDIT APPLICATION

Please print or type

COMPANY NAME <empty>
PHONE ( <empty> )
COMPANY WEBSITE: <empty>
FURNITURE BUYER <empty>
FAX ( <empty> )
ACCESSORY BUYER <empty>
EMAIL <empty>
BILLING ADDRESS <empty>
CITY <empty>
STATE <empty>
ZIP <empty>

SHIPPING NAME AND ADDRESS (IF DIFFERENT THAN ABOVE)
SHIPPING NAME <empty>
STREET <empty>
CITY <empty>
STATE <empty>
ZIP <empty>

Owner(s) <empty>
Address <empty>
A/P Contact <empty>
Phone <empty>
How long in business Under your ownership
[ ] 0-5 months
[ ] 6-12 months
[ ] 1-2 years
[ ] 2-5 years
[ ] Over 5 years
Type of Business?
[ ] Corp
[ ] Partnership
[ ] Sole Proprietorship
Federal I D.# <empty>
Dun & Bradstreet # <empty>

PLEASE CHECK THE BOX NEAREST TO DESCRIBING YOUR BUSINESS
[ ] Architect
[ ] Contract Specifier
[ ] Decorative Accessory
[ ] Department Store
[ ] Designer
[ ] Designer Showroom
[ ] Floral
[ ] Furniture
[ ] Gift/Stationery
[ ] Packer
[ ] Hotel/Restaurant
[ ] Lifestyle
[ ] Mail Order
[ ] Mass Merchant
[ ] Nursery
[ ] Wholesale
[ ] One Time Buyer
[ ] Grocery
[ ] Store with Designer
[ ] Other <empty>

ESTIMATED ANNUAL RETAIL VOLUME
[ ] Under $100K
[ ] $100K - $200K
[ ] $201K - $400K
[ ] $401K - $600K
[ ] Over $600K

## CREDIT APPLICATION (cont.)

## BANK REFERENCES

BANK
ACCOUNT#
CITY
STATE
ZIP
TELEPHONE
CONTACT NAME

## ADDITIONAL REFERENCES

PLEASE LIST COMPLETE NAME, ADDRESS, CITY, STATE, ZIP CODE, TELEPHONE AND FAX NUMBERS & ACCOUNT NUMBER

1. <empty>

2. <empty>

3. <empty>

## TERMS AND CONDITIONS

INAPPLYING FOR OPEN ACCOUNT PRIVILEGES, I AM AWARE OF THE FOLLOWING AND AGREE TO THESE TERMS.

1) Interest will be added at the rate ol 1 1/2% per month (18% per annum on pest due amounts)

2) Should It be necessary for Palocek to resort to a collection agency, I agree to pay all costs and Attorney tees.

3) Shortage/damage calms aro to be made within 15 days of recelpl of merchandise.

4) Invoickig will be made at prevailing prices.

5) An assessment of $25,00 will be charged on aft proved proof-el-deliveries.

6) I hereby authorize our bank & Irade references to release &Normalion for purposes of granting credit.

7) Affixed signature binds signor to personalty guarantee payment of amount duo.

8) Orders under minimum are suberti to a service charge of $35.00

9) Non-sufficient fund (NSF) Fee $25.00

NAME (PLEASE PRINT)
POSITION

SIGNATURE (CORP. OFFICER, PARTNER, SOLE PROPRIETOR OR AUTHORIZED COMPANY EMPLOYEE)
DATE