| GERNATT
ASPHALT PRODUCTS, INC. Taylor Hollow Rd. - P.O. Box 400 - Collins, NY 14034 - Phone: (716) 532-3371 - Fax: (716) 532-9000 APPLICATION FOR CONVENIENCE ACCOUNT |
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| Individual Name ________________________________________________________________________ | ||||
| Company Name ________________________________________________________________________ | ||||
| Address _______________________________________________________________________________ | ||||
| City ___________________________________ | State | ____________ | Zip | ______________________ |
| Phone | _________________ | Fax | ____________________ | _________________________ |
Please complete the following information in full. All information will be held in the strictest confidence. |
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| Ownership: | __ Corporation | __ Partnership | __ Individual |
| Principal Owners: | ||
| Name ______________________ | Address _______________________ | SSN ____________ |
| Name ______________________ | Address _______________________ | SSN ____________ |
| Name ______________________ | Address _______________________ | SSN ____________ |
| Financial | ||
| Name____________________ | Branch_____________________ | Contact________________________ |
| Commercial Credit References: | ||
| Name _______________________ | Address ________________________ | Phone ____________ |
| Fax ______________ | ||
| Name _______________________ | Address ________________________ | Phone ____________ |
| Fax ______________ | ||
| Name _______________________ | Address ________________________ | Phone ____________ |
| Fax ______________ | ||
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Gernatt's credit terms are: Balance is due in full 30 days from date of statement. A FINANCE CHARGE of 1.5% (18% per annum) will be charged after 30 days. Any and all fees incurred in the collection of past due accounts including but not limited to reasonable attorney's fees are the responsibility of the debtor. |
| We certify that all the information on this form is correct, that we fully understand your credit terms and agree to abide by the same. |
| Signature ____________________________________ | |
| Date __________________ | Title ____________________________________ |
| Authorization to release Information |
| To: |
| Bank Name _______________________________________________________ |
| Bank Address _____________________________________________________ |
I / We hereby authorize the above named bank to release any and all information requested by GERNATT ASPHALT PRODUCTS, INC., COUNTRY SIDE SAND & GRAVEL, INC. and / or GERNATT GRAVEL PRODUCTS, INC. relative to my/our checking and savings accounts and loan experience for the purpose of granting credit to the below named account. |
| Signature _______________________________ | Business Name _____________________ |
| Date _________________ | Address ___________________________ |