EmailMe Form - Net 30 Credit Application

Your Company Name *

Your Name *

First Last

Contact Phone *

### - ### - ####

Name of Bank *

Account Number *

Phone *

### - ### - ####

Credit References

Please list three (3) businesses with which you have established Net 30 accounts.

Company Name *

Contact Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Fax *

### - ### - ####

Company Name *

Contact Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Fax *

### - ### - ####

Company Name *

Contact Name *

First Last

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Fax *

### - ### - ####

*

Permissions

By checking here you give permission to the above businesses and financial institutions to release credit information pertaining to credit approval with Alaskan Essences, Inc.

Name of person authorized to buy *

Name of person responsible for accounts payable *

Your Signature *

First Last

By signing this form you agree to abide by the Terms described below.

NET 30 TERMS:
• Payment is due by check within 30 days of the shipping date on your invoice.
• A monthly interest charge of 1 1/2% (18% annum) will be charged on overdue accounts.
• We will not ship new orders if there is an overdue balance on your account.

Please allow 15 business days after application submission to set up Net 30 terms. You will be contacted by email or phone upon approval.

Date Time *

MM / DD / YYYY HH : MM AM/PM