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Essendant Account and credit application - ORS · Other distribution infrastructure? OR. ... the...
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Transcript of Essendant Account and credit application - ORS · Other distribution infrastructure? OR. ... the...
INTERNATIONALACCOUNTANDCREDITAPPLICATION
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Date: PERSONCOMPLETINGAPPLICATIONPICKONE: EssendantCo EssendantIndustrialLLC HOWAPPLIED:Phone InPerson Fax/Mail
BusinessName:
DBA:
Phone: Fax: Emailaddress:
Dunn&Bradstreet(D&B#)(ifknown):
GeneralDescriptionofproductstobepurchased: BILLINGADDRESS
CompanyName:
CompanyAddress:
City: State/Province1: Zip/PostalCode: Country:
Phone: Fax: Emailaddress:
ContactName: USFREIGHTFORWARDERORDELIVERYADDRESS(REQUIRED)
CompanyName:
CompanyAddress:
City: State/Province1: Zip/PostalCode:
Phone: Fax: Emailaddress:
ContactName:
CUSTOMERSHIPTOADDRESS(FINALDESTINATION)
CompanyName:
CompanyAddress:
City: State/Province1: Zip/PostalCode: Country:
Phone: Fax: E‐mail: ContactName:
Doyouexport?Yes No Ifyes,whatcountries?
DoesyourcompanyhaveaU.S.affiliate?Yes No Ifyes,providefullname: Does the customer, including any subsidiaries and affiliates, engage in or expect to engage in activitywith SanctionedCountry2 in thefollowingmanner:
a. Physicallocations(offices,branches,operationsorjointventures),assetsorinvestments Yes No b. Buy,sellorotherwisedealinorfinanceproducts,merchandise,commoditiesorservices? Yes No c. Hasadirector,seniorofficeror10%orgreaterowner/shareholderwhoisa(1)citizen,resident
or(2)governmentalagency/authorityofaSanctionedCountry?Yes No
Webaddress:
TypeofBusiness: DateEstablished(CurrentOwner):
NoofEmployees: NoofLocations: Est.AnnualSales:
OWNERSHIP: SoleOwner Partnership Corporation Proprietorship LLC
1 PleaseprovidefullProvincename.Donotabbreviate. 2 SANCTIONEDCOUNTRIES:Cuba,Iran,Sudan,Syria,NorthKorea
INTERNATIONALACCOUNTANDCREDITAPPLICATION
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PRIMARYCONTACTS:
Owner: (Name) (Phone#) (PercentageOwnership)
President: (Name) (Phone#) (PercentageOwnership)
VicePresident: (Name) (Phone#) (PercentageOwnership)
PurchasingAgent: (Name) (Phone#) (PercentageOwnership)REQUESTEDMODEOFPAYMENT: BankWireTransferonDemand OpenAccountTerms
Desiredcreditlimit:*Acurrentfinancialstatementmustbesubmittedinordertoqualifyforcreditapproval.
PERSON(S)RESPONSIBLEFORPAYMENTS
AP‐Contact/Phone
Contact/Phone
EmailAddress
ShippinginstructionsBackOrders Retain Cancel Doyourequiremonthlystatement: Yes No Acceptsubstitutions: Yes No Acceptpartialshipments: Yes No
CREDITINFORMATION
TRADEREFERENCES:(Namesuppliersofmajorproductsandservices)CompanyName: City: State: Zip: Phone: Fax: Contact: CompanyName: City: State: Zip: Phone: Fax: Contact:
CompanyName: City: State: Zip: Phone: Fax: Contact: BANKREFERENCE:Checking Loan Savings
BankName: City: State: Zip: Phone: Fax: Contact:
IfcreditisextendedI/Weagreetopayalldebtsincurredwiththetermsofsale.However,shouldthedebtbecomepastdue,I/Weexpresslyagree(subjecttostatutoryregulations)topayfinancechargesonthepastdueamountsattherateof1½%permonth(18%annualrate);providedthatnoprovisionofthisagreementrequiresorpermitsthecollectionoffinancechargesinexcessofthemaximumamountpermittedbylaw.I/Weexpresslyagreetopayreasonablecollectioncostsand/orattorney’sfeesincurredinconnectionwiththecollectionofthisaccount.Theapplicantsubmitstothenon‐exclusivejurisdictionofthecourtshavingsitusinthestateofIllinoisandintheUnitedStatesDistrictCourtfortheNorthernDistrictofIllinoisinanysuit,actionorproceedingarisingfromtheextensionofcreditorthesaleofgoodsbyEssendantCoorEssendantIndustrialLLCtotheapplicant for service of process, summons, notice or other document bymailwill be effective service of process for any suit, action or other proceedingbroughtinanysuchcourt.Theapplicantirrevocablywaivesandagreesnottopleadorclaiminanysuchsuit,actionorproceedingbroughtinanysuchcourtthatithasbeenbroughtinaninconvenientforum.
11/16/2015Officer/PrincipalSignature(Authorizedsigneronbankaccount) PrintName Date
Ifrequired,aretheprincipalownerswillingtosignapersonalguarantee? Yes No
Allaccountapplicationsmustbecompletedinfullandlegiblefordepartmentalinputoritwillnotbeprocessed.TheinformationintheAccountandCreditApplicationissubmittedinconfidence.
INTERNATIONALACCOUNTANDCREDITAPPLICATION
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ADDITIONALACCOUNTINFORMATION
HowdidyoufindoutaboutEssendant(whoreferred/whatcompany):
Willtheitemsbeingpurchasedbeusedforanythingotherthanresale? Yes No Ifyes,pleaseexplain:
DESCRIBEYOURBUSINESSLOCATION(S):
Doyouhave: WarehouseorDistributionCenter? Showroomorretailsite? Deliverytrucks? Otherdistributioninfrastructure?OR
isyourbusinessoperatedas: WarehouseorDistributionCenter?
PleasereviewourTermsandConditionslocatedonourwebsitewww.orsnasco.com.Returnthecompletedformviaemailtonewaccounts@orsnasco.comorfax(918)781‐5343
IagreetotheTermsandConditions(Pleaseinitial)
3 PleaseprovidefullProvincename.Donotabbreviate.
INTERNATIONALACCOUNTANDCREDITAPPLICATION
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STATEMENT OF FINANCIAL CONDITION OF AS OF
CASH ACCOUNTS PAYALE
ACCOUNTS RECEIVEABLE SHORT TERM BANK DEBT
INVENTORY ACCRUALS
CURRENT ASSETS CURRENT LIABILITIES
FIXED ASSETS LONG TERM BANK DEBT
TOTAL ASSETS OTHER LONG TERM DEBT
TOTAL DEBT
NET SALES NET WORTH
COST OF SALES FOR MONTHS
GROSS PROFIT
NET INCOME
BY
TITLE
UNIFORM SALES AND USE TAX CERTIFICATE—MULTIJURISDICTION
The below-listed states have indicated that this form of certificate is acceptable. The issuer and the recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change from time to time.
Issued to Seller:
Address:
Enter all bill account number(s): Federal Employer ID Number I certify that:
Legal Name of Company: is engaged as a registered: Wholesaler
DBA Name: Retailer
Manufacturer
Address Seller (California)
Lessor Exporter (Country) Other
and is registered with the below-listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product or service1 to be resold, leased, or rented in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following: Description of Business: General description of tangible property or taxable services to be purchased from the seller: Resale Business Products/Supplies _______________________________________________________________________________________________________________
Separate forms are required for FL, IN, LA, MA, MS, NY, VA, WV, and WY.
STATE State Registration, Seller’s Permit, STATE State Registration, Seller’s Permit, or ID number of Purchaser or ID number of Purchaser
AL MS Attach MS Sales Tax Permit
AR NE
AZ NV
CA NJ
CO NM
CT NC
DC ND
FL Attach Florida DR-13 OH
GA OK
HI PA
ID RI
IL SC
IA SD
KS TN
KY TX
ME UT
MD VT
MI WA
MN WI
MO ____________________________________
For Buyers with locations in states that do not require sales tax registration, please check the appropriate box(es):
AK DE MT NH OR I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or Use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be a part of each order, which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state.
Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter. Authorized Signature:
(Owner, Partner or Corporate Officer)
Title:
Date: