Dealer Credit Application

Burley Account Number (office use only)

Credit Limit Requested

Legal Name of Applicant

Middle

Last

Suffix

Applicant Email

Doing Business As (Include multiple store location names)

Mailing/Billing Address*

Address Line 2

City*

State*

Zip Code*

Country

Business Phone

Cell Phone

Applicant is a

Corporation

LLC

Partnership

Proprietorship

Other

State of Incorporation

Date of Incorporation

FEI Number

Retail Certificate Number

Years in Business

Annual Gross Sales

Owner(s)/Officers

Name

Last Name

Title

Home Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Email

Phone

Name

Last Name

Title

Home Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Email

Phone

Accounts Payable Contact

Last Name

Phone

Email

Financial References

Name of Bank

Bank Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Phone

Contact Name

Last Name

Other Information

Does a bank, insurance company, or other creditor hold a security interest in your accounts receivable and/or inventory for loans advanced or accounts payable?

Yes

No

Please state the names of security interest holder(s)

Have any owners or officers, as an individual, partner, or shareholder ever filed for bankruptcy?

Yes

No

Date and Location

Authorization

The applicant hereby authorizes the above bank to release all information requested. It is understood that all information will be kept confidential.

Trade References

Name

Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Contact Name

Last Name

Contact Email

Contact Phone

Account Number

Credit Limit

Payment Terms

Name

Street Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Contact Name

Last Name

Contact Email

Contact Phone

Account Number

Credit Limit

Payment Terms

Name

Street Address

Address Line 2

City

State/Province/Region

ZIP/Postal Code

Country

Contact Name

Last Name

Contact Email

Contact Phone

Account Number

Credit Limit

Payment Terms

Agreement

The representations provided in this Application are complete and accurate. I understand the information provided will be relied upon in the evaluation and extension of credit terms. I authorize the release at any time of information by creditors listed above as well as other suppliers. The terms and conditions of this Application shall, upon extension of credit by Burley Design, constitute an agreement of sale. The Applicant agrees to be bound to the terms and conditions stated in this Application, and in any subsequent changes made to the account in Burley’s sole discretion. The payment for all sales of goods or services will be according to the terms stated on the Burley Design invoice. The failure to pay on the due date of each invoice shall deem the debt to be delinquent. In the event of a delinquency, Burley Design may impose a late charge at one and one-half percent per month on the delinquent balance until paid. In the event of a delinquen-cy, all collection expenses, including collection agency fees and costs, and attorney’s fees in connection with the collection of the delinquent debt regardless of whether litigation is filed shall be due and payable by the Applicant. Burley Design shall have the right in its sole discretion at any time, without notice to Applicant, to discontinue credit extensions and place the Applicant on a COD and/or credit card basis. The interpretation of this agreement shall be subject to the laws of the State of Oregon, and any necessary legal action shall be brought in Lane County, Oregon. Burley Design reports receivables to national and industry specific credit agencies.

Authorized Signature

Privacy

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Dealer Credit Application

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