Credit Application - Business Account

Basin Cleaning Systems

590 West Main – Vernal Utah 84078

435-789-5888 or www.BasinClean.com

Business Contact Information

Company name:

Purchaser name:                                                                  Company Title:

Phone:

Fax:

E-mail:

Primary business address:

City:

State:

ZIP Code:

Date business commenced:

Sole proprietorship:

Partnership:

Corporation:

Other:

Business and Credit Information

Registered company address:

City:

State:

ZIP Code:

Telephone:

Fax:

E-mail:

Billing Information

Do you require PO’s

Yes      No

Send invoices to:

Pay with Credit Card on File

Card type:                       Account#:                                         Sec#

Other information:

Names of persons able to charge on this account

Agreement

1.   All invoices are to be paid 30 days from the date of the invoice.

2.   Claims arising from invoices must be made within seven working days.

3.   By submitting this application, you authorize IMC-Basin Cleaning Systems to make inquiries concerning your business/trade references.

Signatures

Title:

Date:

Title:

Date: