Credit Application

Click on the link below to download our credit application.
Credit Application

Or fill out the form below.

Customer Application for Credit

Name of Business:
  *
Phone:
  *
Billing Address:
  *
Delivery Address:
Type of Business:
Corporation
Partnership
Proprietorship
Name of Owner(s):
Home Address:
Authorized Buyer:

Banking References

Name of Bank:
Type of Account:
Address:
Account No.:
Phone No.:
Contact:

Business References

(1) Name:
(1) Contact:
(1) Address:
(1) Phone:
-----------------------------------
(2) Name:
(2) Contact:
(2) Address:
(2) Phone:
-----------------------------------
(3) Name:
(3) Contact:
(3) Address:
(3) Phone:

 

Resale Number:
Credit Requirements:
Estimated Dollar Value:
Total Assets:
Total Liability:
Net Worth:

In consideration of the extension of credit by Heiden’s Inc. to the above applicant it is understood and agreed that all bills are due at the term stated on the sale invoice and if not paid, a 1.5 percent service charge will be assessed. In the event the account had to be turned over to an attorney for collection I/We agree to be responsible for reasonable attorney’s fees incurred by Heiden’s Inc.

Customer Signature:
Date:

544 S. STATE COLLEGE BLVD.
FULLERTON, CA, 92831
Office (714) 525-3414
(714) 525-6440
FAX (714) 525-8049

* Required field