Credit Form » Johnstone Supply The Balsan Group

Credit Application

Step 1 of 7

Business Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Website
Email*
Phone*
Fax
Nearest Johnstone Supply Store*
If you do not select a store your application will not be processed.
Type of Business*
Contractor License #*
No. of Employees*
Date Established*
MM slash DD slash YYYY
OWNERSHIP INFORMATION
Business Classification*
- Incorporation
- LLC
- Proprietorship
- Partnership
- LLP
- Governement
Date of Formation*
MM slash DD slash YYYY
State of Formation
Fed ID #*

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Principal Owners, Officers and Partners
Name*
First Last
Title*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Social Security #
Check to add additional owners
- Add
Name*
First Last
Title*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Social Security #
Check to add more
- Add
Name*
First Last
Title*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Social Security #
Bills are paid by*
- Our company as listed on the first page of this application
- A different or parent company
Company Name*
Phone*
Fax
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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BANK REFERENCES
1. Select type of account*
- Savings
- Checking
- Loan
Bank Name*
Account #*
Branch
Address*
Street Address Address Line 2 City State ZIP Code
2. Select type of account
- Savings
- Checking
- Loan
Name
Account #
Branch
Address
Street Address Address Line 2 City State ZIP Code

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COMMERCIAL TRADE REFERENCES
Give only names of those you buy from on OPEN ACCOUNT. References WILL NOT be considered unless FULL NAMES and ADDRESSES are included.
1. Reference Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Account #
2. Reference Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Account #
3. Reference Name*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Fax
Account #

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EMPLOYEE REFRIGERANT HANDLING CERTIFICATE
Employee Name
Certificate #
Upload a copy of the refrigerant certificate
Max. file size: 100 MB.
Do You Have Additional Employee Refrigerant Certificates?
- Yes
Employee Name
Certificate #
Upload a copy of the refrigerant certificate
Max. file size: 100 MB.
Employee Name
Certificate #
Upload a copy of the refrigerant certificate
Max. file size: 100 MB.

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GUARANTY
I,*
I,
First Last
XXX-XX-XXXX*
having a Social Security Number of
and residing at the address of*
and residing at the address of

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Buyer*
for and in consideration of Johnstone Supply’s (“Seller”) extension of credit to
Title*
of which I hold the title of
City*
hereby absolutely, irrevocably, and unconditionally guarantee to Seller or its successors the payment at
State*
in the State of
of any obligation incurred by the Buyer or its successors. In the event of Buyer’s failure to pay any of the obligations of the Buyer when due, I hereby agree to bind myself to pay to Seller, on demand, the entire sum owed and due to Seller pursuant to the terms of the credit agreement, including but not limited to, the principal sum, late fees, accrued interest, collection costs, and attorney fees. I hereby expressly waive notice of default, notice of demand, and notice of non-payment. I further waive my right to consent to modification and/or renewal of the credit agreement hereby guaranteed. I understand, acknowledge, and agree that this Guaranty shall be a continuing and irrevocable guarantee of payment to Seller and indemnity for any such indebtedness of the Buyer. I further understand, acknowledge, and agree that this Guaranty will survive any modification and/or renewal of the credit agreement. If Seller files suit to enforce this Guaranty, I acknowledge and consent to Seller’s power to file suit against me in any court in the state and county of Seller’s choice. I further acknowledge and consent to personal jurisdiction over me by such court, waive any objection to the placement of venue in such court, and agree that service of process may be made upon me by mailing a copy of the court summons to the above address. Such service of process shall be deemed effective upon my receipt. By signing below, I fully agree to and am bound by the terms described herein.
Signature
Signature Confirmation
Type Name
First Last
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Credit Application

Step 1 of 7

OWNERSHIP INFORMATION

Principal Owners, Officers and Partners

BANK REFERENCES

COMMERCIAL TRADE REFERENCES

EMPLOYEE REFRIGERANT HANDLING CERTIFICATE

GUARANTY