Credit Application Start

Primary Contact Name*

First Last

Primary Contact Email*

Primary Contact Phone Number*

We may contact you with questions regarding this application

Primary Contact Title/Role*

Legal Company Name*

DBA (Doing Business As)*

If same as legal name, please enter the legal name here

Legal Physical Address*

Street Address Address Line 2 City State ZIP Code

Business Main Phone Number*

Business Website*

Part of a Parent Company*

Yes

No

Parent Company Legal Name*

Parent Company Address*

Street Address City State ZIP Code

Parent Company Phone*

Relationship to Parent Company*

Shipping Information

Ship-to Address*

Street Address Address Line 2 City State ZIP Code

Ship-to Contact*

Ship-to Contact Title/Role*

Ship-to Contact Phone*

Ship-to Contact Email*

Additional Ship-to?*

Yes

No

More than two Ship-to's?*

Yes

No

If Yes, please upload a separate sheet listing all locations

File*

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Ship-to Address Location 2*

Street Address Address Line 2 City State ZIP Code

Ship-to Contact*

Ship-to Contact Title/Role*

Ship-to Contact Phone*

Ship-to Contact Email*

Billing Address for Invoices/Statements*

Same as legal address

Same as Ship-To address

A different address

Address*

Street Address Address Line 2 City State ZIP Code

Email Address(es) to Receive Invoices and Statements*

Please separate multiple addresses with a comma

Accounts Payable Contact*

Accounts Payable Phone*

Accounts Payable Email*

Federal ID Number (EIN)*

Year Established*

State Business is Registered in*

State Registration Number*

If not a requirement in your state, please enter "N/A"

Principal Owner(s) or Stockholder(s)*

% Ownership(s)*

Principal Owner or Stockholder Home Address*

No PO Box

Social Security Number*

Please do not enter dashes

Has the Applicant, Applicant's Parent, Owner or Affiliates ever Filed for Bankruptcy?*

Yes

No

If yes, please upload a letter of explanation

File*

Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB.

Business Entity Type*

Business Classification*

Please Name Other Classification*

GPO Affiliation*

Other GPO*

Please name GPO

GPO Member ID*

Payment Terms*

Credit Card

Net 30 Days

Other

Electing to pay by credit card will incur a 3% processing fee, calculated off the order value

Anticipated Monthly Purchases*

Please enter a number from 1 to 1000000.

Other Payment Terms*

Trade Reference 1 Company Name*

Trade Reference 1 Account Number*

Trade Reference 1 Contact Name*

Trade Reference 1 Contact Email*

Trade Reference 2 Company Name*

Trade Reference 2 Account Number*

Trade Reference 2 Contact Name*

Trade Reference 2 Contact Email*

Primary Bank Name*

Bank Account Number*

Bank Contact Name*

Bank Contact Email*

Terms and Conditions*

I agree

1) Upon approval of this Application, Chommerce, LLC, in its sole discretion, and notwithstanding any request of Applicant, shall have the right to terminate Applicant’s credit privileges under this Application at any time without prior notice to Applicant, except as otherwise provided by law.

2) All purchases by Applicant of goods and/or services from Chommerce, LLC will be made in accordance with the terms and conditions of this Application and any invoices and/or other documents evidencing Applicant’s obligations to Chommerce, LLC, all of which are incorporated herein by reference.

3) The entire outstanding balance due to Chommerce, LLC on all invoices shall become due in full immediately upon default in the payment of any invoice. Applicant agrees to pay interest each month at the highest rate permitted by law on any past due amounts until collected, and Applicant agrees to pay all costs of collection incurred by Chommerce, LLC, including attorneys’ fees and expenses, should a default in payment or any other obligation of Applicant to Chommerce, LLC occur.

4) If this Application is not fully approved or if any other adverse action is taken with respect to Applicant’s credit with Chommerce, LLC, Applicant has the right to request within 60 days of Chommerce, LLC notification of such adverse action, a statement of specific reasons for such action, which statement will be provided within 30 days of said request. To obtain the statement of specific reasons, please contact Chommerce, LLC Controller. The Federal Equal Credit Opportunity Act prohibits creditors from discrimination against credit Applicants on the basis of race, color, religion, national origin, sex, marital status, or age (provided that the Applicant has the capacity to enter into a binding contract); because all or part of the Applicant’s income derives from any public assistance programs, or because the Applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning the creditor is the Federal Trade Commission, Washington, D.C.

5) This Application and all transactions between Applicant and Chommerce, LLC shall be governed by and interpreted in accordance with the laws and decisions of the state of Delaware, without regard to the conflicts of law provisions thereof. Applicant and Chommerce, LLC irrevocably agree, and hereby consent and submit to the non-exclusive jurisdiction and venue of the Courts of Washington, regarding all actions and proceedings arising from, relating to, or in connection with this Application.

6) If Applicant ceases doing business with Chommerce, LLC for any reason, Applicant will immediately purchase from Chommerce, LLC all remaining proprietary/special order items in Chommerce, LLC inventory that were acquired specifically to service Applicant.

7) Applicant expressly agrees that Chommerce, LLC shall not be responsible for any product nonconformity as to quantity, quality, or price, unless noted on the original delivery receipt at the time of delivery or unless Chommerce, LLC is notified in writing of any such nonconformity within three (3) days of delivery, by certified mail return receipt requested.

8) Except as to quantity of goods ordered, no terms and conditions set forth in any purchase order or other form of Applicant will apply to sales by Chommerce, LLC to Applicant.

9) Liability for collection fees and costs: The undersigned agrees to pay within stated invoice terms and agrees to pay any and all collection costs if this account is referred for collection, or if suit is brought to collect this amount. Further, it is agreed that the undersigned will pay all costs and reasonable attorney’s fees, including costs and reasonable attorney’s fee incurred on any appeal to an appellate court.

10) Authorization to purchase and make credit inquiry: The undersigned is authorized to make purchases and grants permission of Chommerce, LLC. to make inquiry on financial, credit and related matters and their financial institution(s), lending firm(s) and references listed elsewhere on this application and they are hereby authorized to give you any information their files contain.

Signature*

Name*

Printed Name

Title*

Date

Company Name*