Social Security or Federal Identification Number (circle one)
Funding/Sponsoring Agency/Individual as it appears with credit reporting agencies.
name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
accounts payable contact_________________________________________    ext_______    
type of organization
Corporation
Partnership
Proprietor
owners, partners, or corporate officers
name_____________________________    title____________    phone___________________    
name_____________________________    title____________    phone___________________    
name_____________________________    title____________    phone___________________    
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)
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
credit references- net 30 references (please do not include credit cards)
name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
account number_________________________    phone______________________    
name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
account number_________________________    phone______________________    
name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
account number_________________________    phone______________________    
financial institution references
bank name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
account number_________________________    phone______________________    
bank name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
account number_________________________    phone______________________    
ship to information
name___________________________________________________
address_________________________________________________
city___________    state____________    zip___________________    
phone_________________________    fax______________________    
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_________________