Application

Credit Application

Please print the application linked and fill it out completely.
Fax it to: (800) 275-8583
E-mail it to: [email protected]

Application for Credit

Or complete the form below, once you click submit it will open up an e-mail, click send.
The form below must be submitted on a desktop, it is not mobile compatible.

Ship to:

Company Name:

Address:

City:

State/Province:

Zip:

Bill to - Omit if same as Shipping:

Company Name:

Address:

City:

State/Province:

Zip:

Contact Information:

Phone Number:

Accounts Payable Contact Name:

Accounts Payable Contact E-Mail:

Business in the State of:

Number of Years in Business:

Select one:
Sole Proprietorship
Partnership
Corporation

Bank Data:

Bank Name:

Bank Address:

Bank City:

Bank State/Province:

Bank Zip:

Bank Phone Number:

Bank Contact Name:

Bank Contact E-Mail:

Please list all Officers of the Company - Owners or Partners:

1 Name:

1 Title:

1 Full Address:

1 Phone Number:

2 Name:

2 Title:

2 Full Address:

2 Phone Number:

Credit Trade References - Two are Mandatory:

1 Reference Company:

1 Reference Full Address:

1 Reference Contact:

1 Reference Phone Number:

2 Reference Company:

2 Reference Full Address:

2 Reference Contact:

2 Reference Phone Number:

3 Reference Company:

3 Reference Full Address:

3 Reference Contact:

3 Reference Phone Number:

All past balances are subject to a 1.5% late charge.

I, We, the undersigned, being the owner, or principal stockholder of the entity, known as , who have made application for credit with you, hereby agree for valuable consideration to unconditionally indemnify you from any and all losses you might sustain by reason of the entity mentioned above failed to pay its obligations when due for goods and/or services delivered by you, sold by you and/or for work performed by you, and I, we, do agree to waive notice of default, hereby giving you the right to extend the time of payment without limitation and do individually and severally agree to be personally liable for the obligations of and/or for any goods, services and/or merchandise or credit extended/expended by you. The undersigned hereby authorizes D&S Vending, Inc to investigate the credit of the entity and/or the individual submitting this document with any of its suppliers, financial institutions, credit bureaus, or credit reporting agencies and to retain this data in our file for future reference.

Date:

Name of Submitter of Guarantor:

Signature of Submitter of Guarantor: