Social Security or Federal Identification Number (circle one)

Name ______________________________________

Address_____________________________________________________________________

City_____________________  State ___ Zip Code_____________

Phone Number (      )___________  Fax Number (     )____________

Accounts Payable contact _____________________________________Ext._______

Type of Organization

Corporation

Partnership

Proprietor

Owners, Partners, or Corporate Officers

Name_________________________Title______________________Phone Number_______________ Name_________________________Title______________________Phone Number_______________ Name_________________________Title______________________Phone Number_______________

Line of business _____________________________________________

Year Established _______________Student Enrollment ___________________

Does your organization use purchase orders?     Yes    No 

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

 Taxable

 Tax-exempt  #____________

Billing Address History (include five years if applicable) 

Street Address______________________________________________________________________

City_____________________  State ___ Zip Code_____________

Phone Number (      )___________  Fax Number (     )____________

Street Address______________________________________________________________________

City_____________________  State ___ Zip Code_____________

Phone Number (      )___________  Fax Number (     )____________

Street Address______________________________________________________________________

City_____________________  State ___ Zip Code_____________

Phone Number (      )___________  Fax Number (     )____________

Street Address______________________________________________________________________

City_____________________  State ___ Zip Code_____________

Phone Number (      )___________  Fax Number (     )____________

Credit References- Net 30 references (please do not include credit cards)

Name__________________________________________________________________________

Street Address __________________________________________________________________

City_____________________  State ___ Zip Code_____________

Account Number ___________________Phone Number (      )___________ 

Name__________________________________________________________________________

Street Address___________________________________________________________________

City_____________________  State ___ Zip Code_____________

Account Number ___________________Phone Number (      )___________

Financial Institution References

Bank Name _____________________________________________________________________

Street Address___________________________________________________________________

City_____________________  State _____ Zip Code_____________

Account Number ___________________Phone Number (      )___________ 

Bank Name _____________________________________________________________________

Street Address___________________________________________________________________

City_____________________  State _____ Zip Code_____________

Account Number ___________________Phone Number (      )___________  

Ship to Information

Individual or Organization Name ______________________________________________________

Street Address_____________________________________________________________________

City_____________________  State ___ Zip Code_____________

Phone Number (      )___________  Fax Number (     )____________

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 Discount School Supply 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 Discount School Supply of any changes in financial and ownership status.  Applicant shall reimburse Discount School Supply for all expenses incurred resulting from all costs of collection, including attorney fees and legal expenses of any indebtedness owed on past due balances.

Signature________________________________________________Date_________________