HESCO APPLICATION FOR CREDIT
Please select which company you wish to apply for credit with. (Please choose only one).
 
HESCO HEPSCO

Application Date: ___/___/______

Failure to complete areas of this form will result in the delay of credit approval.
Please read this form carefully.

Company Name: __________________________ Dun & Bradstreet Rating: ___________________
Sales tax exempt?    Yes      No (Please complete “Annual Resale Certificate”)
   
Street: __________________________ City: __________________________
State: __________________________ Zip: __________
   
Shipping Address(es) :  
_________________________________________ _________________________________________
_________________________________________ _________________________________________
_________________________________________ _________________________________________
_________________________________________ _________________________________________
   
County: __________________________ Telephone: ( ____ ) ___________________
Fax: ( ____ ) ___________________  
   
Owner(s) :  
_________________________________________ _________________________________________
_________________________________________ _________________________________________
   
Have any of the owners, officers or partners, as applicable, ever filed bankruptcy?      Yes      No
If yes, when and where? ___________________________________________________________________
   
At present location since: _______________________ Year established: _______________________
Purchase orders required?    Yes      No  
   
Please        fax       mail        email         my invoices.
e-mail address: _______________________________  
   
Authorized Representative(s):  
_________________________________________ _________________________________________
_________________________________________ _________________________________________
   

HESCO Service Representative

 
_________________________________________  
   
Current financial statements enclosed?   Yes      No

(Financial Statements should be submitted to receive a credit line in excess of $20,000.00)

   
Bank name : _______________________________  

("Customer Authorization" form - Schedule A - must be submitted to permit our request at your bank)

Address: __________________________ City: __________________________
State: __________________________ Zip: __________
Telephone: ( ____ ) ___________________ Fax: ( ____ ) ___________________
Checking Account No: _______________________  
   
Creditor Information:
1)
Company:  
 
Address:  
 
City:   State:   Zip:  
 
Phone:   Fax:  
2)
Company:  
 
Address:  
 
City:   State:   Zip:  
 
Phone:   Fax:  
   
3)
Company:  
 
Address:  
 
City:   State:   Zip:  
 
Phone:   Fax:  
4)
Company:  
 
Address:  
 
City:   State:   Zip:  
 
Phone:   Fax:  
   

The undersigned certifies that the above information is true and that application is hereby made for the extension of credit by HESCO. HESCO is hereby authorized and granted permission to conduct a complete credit background check and obtain credit information (including a consumer credit report) from any agency or source deemed necessary for the verification of credit and financial status. It is agreed that, if credit is extended, all sales will be made in accordance with the terms set forth below.

TERMS: INVOICE PAYABLE, NET BY THE 30TH OF THE MONTH FOLLOWING RECEIPT EXCEPT AS OTHERWISE STATED ON AN APPLICABLE INVOICE. INTEREST ON PAST DUE ACCOUNTS SHALL ACCRUE AT THE RATE OF 1½% PER MONTH OR 18% PER ANNUM. ATTORNEY FEES, COLLECTION FEES AND COURT COSTS ARE TO BE PAID BY CUSTOMER IF LEGAL ACTION IS INSTITUTED FOR THE COLLECTION OF THE INVOICE. THE CUSTOMER AND ALL GUARANTORS WAIVE ANY AND ALL RIGHTS TO VENUE UNDER CHAPTER 47, FLORIDA STATUTES, INCLUDING ANY AMENDMENTS THERETO, AGREE THAT ANY ACTION BROUGHT TO COLLECT ON THE ACCOUNT SHALL BE BROUGHT IN ANY COURT OF COMPETENT JURISDICTION IN POLK COUNTY, FLORIDA, AND WAIVE ALL RIGHTS TO A JURY TRIAL.

   
Person accepting above terms of payment:
   
Name (signature): Title: ____________________________________
                         ______________________________  
Name (print) :         Driver's License No: __________________________
                         ______________________________  
   
Credit Amount Requested: $_____________________  
   

For Corporation or Partnership, you may be asked to execute Schedule B, the personal guarantee.
 
Schedule A - Please fax this completed form to us, or to your bank:
 

MEMORANDUM
To: __________________________ Date: ___/___/______
     Banking Institution
     __________________________
     Location
From: __________________________
         __________________________
         __________________________
RE: Authorization to Release Information, Account # _________________________

This is to authorize you, as our Trade Banking reference, to release information concerning our bank account number shown above, to HESCO for the purposes of credit approval. We understand all information released to HESCO will be kept strictly confidential by them. Please answer the questions below and fax this form directly to:

HESCO      Credit Department      863-547-1009
ACCOUNT OPEN SINCE ___/___/______
BALANCE ON ________        $_______________
                         (date)
NUMBER OF NSF, LAST 12 MO _______
 

Thank you for your prompt attention to this inquiry.

AUTHORIZED BY:
Signature: _______________________
Print Name: _______________________
Company: _______________________
Title: _______________________
 
 
 
Schedule B
UNCONDITIONAL GUARANTEE
 
The undersigned joint and several guarantor(s), (collectively the "Guarantor") in consideration and for the purpose of inducing Highland-Exchange Service Cooperative, (“HESCO”) to extend credit to the customer (“Customer”) indicated above, without which HESCO would not do, hereby unconditionally guarantees to HESCO, its transferees, successors or assigns, the prompt payment of all credit extended Customer by HESCO pursuant to this Credit Application. Guarantor waives presentment, demand, protest, notice of dishonor or nonpayment or other default by Customer with respect to any liabilities or obligations of Customer to HESCO. In the event Customer shall be in default in the payment of any amounts due HESCO, Guarantor shall immediately, upon demand by HESCO, pay to HESCO the full amount then in default, together with any costs and reasonable attorneys' fees incurred by HESCO, and together with any interest accruing pursuant to this Credit Application, and such obligations shall become the direct and primary obligations of Guarantor. There shall be no duty or obligation of HESCO to first institute proceedings against Customer or to exhaust any remedy in law or in equity against Customer before bringing suit or instituting proceedings of any kind against Guarantor. This Guarantee shall bind the heirs and legal representatives of Guarantor. Guarantor hereby expressly waives any right to a jury trial, and agrees that venue for any action hereon shall lie in the court of competent jurisdiction in Polk County , Florida .
 
IN WITNESS WHEREOF, Guarantor has executed this Guarantee this ____ day of ________, 200 __.
 
Signed, sealed and delivered in the presence of: _______________________________________.
                                                                                             "GUARANTOR"
Witness: _______________________________________
Print Name: _________________________________ SS # : _________________________________
Home Address: _________________________________________________________________________
 
Witness: _______________________________________
Print Name: _________________________________ SS # : _________________________________
Home Address: _________________________________________________________________________
 
Witness: _______________________________________
Print Name: _________________________________ SS # : _________________________________
Home Address: _________________________________________________________________________