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On Account Application
-- ALL INFORMATION IS REQUIRED --


Billing Information

Business or Organization Name  

Bill to Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx  

Fax Number (xxx) xxx-xxxx 

Social Security or Federal Identification Number 

Email Address  



Ship to Information (if applicable)

Individual or Organization Name  

Street Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx 

Fax Number (xxx) xxx-xxxx 




Billing Address History (include five years if applicable)

1.  Street Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx 

Fax Number (xxx) xxx-xxxx 



2.  Street Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx 

Fax Number (xxx) xxx-xxxx 



3.  Street Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx 

Fax Number (xxx) xxx-xxxx 



4.  Street Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx 

Fax Number (xxx) xxx-xxxx 



5.  Street Address  

City   State   Zip Code  

Phone Number (xxx) xxx-xxxx 

Fax Number (xxx) xxx-xxxx 



Organization/Business Account Information Only Owners,
Partners, or Corporate Officers


1.  Name  

Title  

Phone Number (xxx) xxx-xxxx 



2.  Name  

Title  

Phone Number (xxx) xxx-xxxx 



3.  Name  

Title  

Phone Number (xxx) xxx-xxxx 



Contact for Bookkeeping/Accounts Payable  

Phone Number (xxx) xxx-xxxx 

Type of Organization 

Line of Business  

Year Established     Enrollment  

Funding/Sponsoring Agency (if applicable)  

Does your organization use purchase orders?  


Tax Status (Tax will be charged unless exemption certificate is provided.)




Credit References

1.  Name  

Street Address  

City   State   Zip Code  

Account Number  

Phone Number (xxx) xxx-xxxx 



2.  Name  

Street Address  

City   State   Zip Code  

Account Number  

Phone Number (xxx) xxx-xxxx 



Financial Institution References

1.  Bank Name  

Street Address  

City   State   Zip Code  

Account Number  

Phone Number (xxx) xxx-xxxx 



2.  Bank Name  

Street Address  

City   State   Zip Code  

Account Number  

Phone Number (xxx) xxx-xxxx 





Terms and Credit Purchase Agreement

     The undersigned certifies that all the information on this form is correct and that the firm is not insolvent and the company is in good standing. The applicant authorizes Environments to obtain necessary credit information at any time from any source including a credit bureau report and agrees to pay for purchases according to the terms of Net 30.

     Applicant warrants that all information is accurate as of date signed and will notify in writing to Environments of any changes in financial and ownership status. Applicant shall reimburse Environments for all expenses incurred resulting from all costs of collection, including attorney fees and legal expenses of any indebtedness owed on past due balances.



Electronic Signature 

(by clicking the Submit Button, you agree to the Terms and Agreement above)



For Questions, Please call
(877) 362-6759 Phone
(877) 362-6769 Fax

Environments®
Attn: Accounting Credit Dept.
PO Box 6013
Carol Stream, IL 60197-6013
or
email openacct@excelligencemail.com
Thank you!

3.11.16




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