Your completed application should be faxed to accounting at Fax: 203-269-0162

New England Steamway appreciates the opportunity to supply you with our products. In order to avoid delays in shipments or the need to send products C.O.D., New England Steamway will extend credit terms of net 30 days to qualified customers. If you wish to open a 30 Day Account, simply printout this form , supply the information requested, sign and fax the form back to our accounting department. Until approval is received, all purchases must be paid by cash, C.O.D., Visa, Discovery or MasterCard. Shipments made C.O.D. to you are not an inconvenience to us, we are just offering an alternate method of payment that may be more convenient for you.

COMPANY INFORMATION:

Company Name:__________________________________________________ Date:__________________
Street Address:_____________________________________ City:_________________________________
State:_______________ Zip Code:_______________ Phone Number:______________________________
Type of Business:_________________________________ Fed ID Number:__________________________
Year Company Established:____________________ Tax Exemption Certificate:______________________
Resale Number (Please Furnish Copy of Certificate):____________________________________________

OWNER (S)/OFFICER (S) INFORMATION:

Check one:<CORPORATION>   <PARTNERSHIP>   <PROPRIETORSHIP>

Name:_____________________________________ Social Security Number:________________________
Street:______________________________________ City:_______________________________________
State:_____________________ Zip:____________ Home Phone:__________________________________
 
Name:____________________________________ Social Security Number:_________________________
Street:_______________________________________ City:______________________________________
State:_____________________ Zip:_____________ Home Phone:_________________________________

Years Under Current Management:__________________________________________________________

TRADE REFERENCES (COMPANIES THAT EXTEND YOU NET TERMS):

Company Name:_______________________________ Account Number: ___________________________
Street:_________________________________ City:____________________________________________
State:_____________________ Zip:____________ Phone:_______________________________________

Company Name:_______________________________ Account Number: ___________________________
Street:_________________________________ City:____________________________________________
State:_____________________ Zip:____________ Phone:_______________________________________

Company Name:_______________________________ Account Number: ___________________________
Street:_________________________________ City:____________________________________________
State:_____________________ Zip:_____________ Phone:______________________________________

BANK REFERENCE:

Bank Name:___________________________________ Account Name:____________________________
Street Address:________________________________ Account Number: __________________________
City:_________________________ State:_______ Zip:________ Contact:__________________________
Phone Number: ___________________

APPLICANT MUST READ AND SIGN
I hereby certify that I am duly authorized to make this application and allow verification of the above information. I guarantee payment of all bills when due, and acknowledge a delinquency assessment at the maximum allowable interest rate by law until paid. In the event the account is placed with an attorney for collection or suit of the same is collected through probate or bankruptcy proceedings, then an additional reasonable amount shall be added to the same as attorneys fees. It is understood and agreed that any checks returned to us by your bank shall be charged a service fee. Any account with an Non Suffient Funds check shall be placed on a C.O.D. cash only basis for a probationary period to be determined by the Credit Department. This guarantee shall be continuing, absolute and unconditional and shall remain in full force and effect until written notice of its discontinuance is sent by certified mail or registered mail, return receipt requested and actually received by New England Steamway and until any and all indebtedness existing before receipt of such notice shall be paid in full.

Name:__________________________ Signature:______________________________ Date:____________

INSTRUCTIONS FOR PROCESSING THIS FORM:
1. Fill out form completely and sign were indicated above
2. Fax completed form to number listed in red at the top of this application
3. If you have any questions, please call us toll free at 800-322-5321
4. If you wish to mail in this application, send it to:

New England Steamway
128 East Street
Wallingford, CT 06492

Thank you for the opportunity to be of service.