Credit Application | U.S. Polymers Inc.

We submit herewith the following information to be used as a basis for extension of credit.

Trade or Corporate Name

Initial Order ($)

Street Address

Monthly Requirement ($)

City, States, and ZIP Code

Date Business Began

Telephone #

Sales/Use Tax Exempt #

(Provincial Sales Tax Exemption in Canada)

I. Type

Type

Proprietorship
Partnership
Corporation

Ownership

Public
Private

Note: Notify us in writing of any change in ownership, structure, or organization within 30 days.

II. Owner, Partners or Officers (Name and Title)

(Name and Title)

III. Parent Company, Divisions or Subsidiaries if applicable

(Name, address, relationship)

IV. Banking Reference

(Name, complete address, telephone number & account numbers)

V. Trade Reference

1.) (Name, complete address, telephone number & fax number)

2.) (Name, complete address, telephone number & fax number)

3.) (Name, complete address, telephone number & fax number)

VI. Financial Statement

Please attach a copy of your latest Financial Statement, signed by owner, partner, or officer of the business.

Fiscal Year End

Sales last fiscal year ($)

Current Net Worth ($)

Dun & Bradstreet Duns Number

VII. Other Information

You agree to pay within an invoice's stated payment terms.

Yes
No

Are you a co-maker, endorser or guarantor on any obligations?

Yes
No

Are there judgments or lawsuits pending against you?

Yes
No

Have you filed for bankruptcy in the last seven years?

Yes
No

Are you capable of making electronic fund payments?

Yes
No

The undersigned certifies that the information set forth herein is correct and complete in all respects and authorizes release of credit information requested form bank and trade references provided.

In the event that U.S. Polymers, Inc, agrees to sell product to the undersigned, the undersigned promises to pay all sums due to U.S. Polymers, Inc, for the product within agreed credit terms from date of invoice. Further, the undersigned agrees to pay the maximum interest rate allowed on all balances that have not been paid within such terms. Additionally, the undersigned agrees to promptly pay any and all costs of collection, including attorney's fees and/or collection agent fees, incurred in the collection of any outstanding balances owing, Jurisdiction of the Massachusetts courts will apply to any dispute between Buyer and Seller and to the interpretation and enforcement of this Contract. This Contract and not be changed except such change is submitted in writing and accepted by signature of an authorized agent or office of U.S. Polymers, Inc.

Signature (by authorized agent)

By my eSignature below, I verify that I understand the culpability of an electronic signature as the legally binding equivalent of my physical (handwritten) signature. I confirm all information completed in this electronic form and authenticated by my signature to be accurate and truthful and agree to all credit terms hereto outlined by U.S. Polymers for the extension of credit.

Date

Title