A Better Air Gap
Application For Credit

Company Name:
Phone: Fax:   E-Mail:
Mailing Address:
City:   State: Zip Code:
Shipping Address: 
City:   State: Zip Code:
Internet Address: 
Name of Purchasing Contact:
Full Name of Owner or Officer:
State Resale Number:  Federal Tax ID Number:

Trade References

Company Name:
Mailing Address:
Phone: Fax:   E-Mail:
City:   State: Zip Code:

Company Name:
Mailing Address:
Phone: Fax:   E-Mail:
City:   State: Zip Code:

Company Name:
Mailing Address:
Phone: Fax:   E-Mail:
City:   State: Zip Code:

The undersigned hereby states that he/she is the owner or the officer of the company and personally guarantees all the amounts due to J.H. Verneco, Inc. including any service charges. This personal guarantee shall remain in full force and effect as long as credit is extended to the undersigned for any business he/she owns or is associated with until revoked in writing and covers all credit expenses, even if it is in excess of credit limit.
The undersigned agrees and guarantees that in the event of default in payments when due, that he/she will pay in addition to all sums due, all costs of collection, including reasonable attorney fees and court costs incurred by J.H. Verneco, Inc.
The undersigned agrees to pay a service charge of 1.5% per month or 18% on an annual rate for all invoices not paid on or before the due date: Net 15 days.

Signature/Title: Date:

The above information is for the purpose of obtaining credit and is warranted to be true. I/We herby authorize J.H. Verneco, Inc. to investigate the references listed pertaining to my/our credit and financial responsibility.
Please return completed form to address or facsimile below.
J.H. Verneco, Inc,    P.O. box 811,    515 Golden Avenue,   Columbia City, IN 46725,                Fax: 260-244-3540