Step 1 of 8 – Billing 12% BillingBusiness Name (DBA) Trade Name Billing Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Corporation Telephone NumberA/P Fax NumberAccounts Payable Contact Email DeliveryDelivery Address Same as Billing Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone Number (Site)Fax Number (Site)Federal Tax Identification -or- State Sales & Use Tax Permit Number Purchasing Contact Title Anticipated Monthly VolumePurchase orders required? Yes No Business InformationBusiness was … Started on Incorporated on Date Started/Incorporated on Month Day Year Is applicant a New Owner? Yes No Applicant Owns or Rents its present place of business Owns Rents Landlord/Mortgage Holder Telephone NumberAddress Street Address Please check appropriate box for business type: Sole Proprietorship Partnership Limited Partnership Limited Liability Partnership Limited Liability Company L.C.C. Corporation State of RegistrationSelect StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingRegistration # Franchise of Owner/Proprietor, Partners, or Corporate OfficersName Title Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Telephone NumberSocial Security Number State and Drivers License Number Add another Owner/Proprietor, Partners, or Corporate Officer? Yes No Add Owner/Proprietor, Partner, or Corporate OfficerName Title Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Telephone NumberSocial Security Number State and Drivers License Number Add another Owner/Proprietor, Partners, or Corporate Officer? Yes No Add Owner/Proprietor, Partner, or Corporate OfficerName Title Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Telephone NumberSocial Security Number State and Drivers License Number Banking InformationBank Name Bank Telephone NumberBank Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Checking Account Number Savings Account Number Local Food Distributor ReferencesReference #1Name Address Telephone NumberAccount Number Reference #2Name Address Telephone NumberAccount Number Reference #3Name Address Telephone NumberAccount Number Reference #4Name Address Telephone NumberAccount Number Agreement of Terms and ConditionsThe undersigned (“Purchaser”/”Applicant”) agrees that all purchases made by Purchaser from Brothers Produce of Dallas, Inc. (“Brothers”/”Seller”) are subject to the following terms and conditions: All amounts due for goods and services purchased from Seller are payable at the Seller’s office in Garland, Dallas County, Texas. Purchaser agrees that such amounts are not payable in installments. Pursuant to the Seller’s policy, any delinquency in payments could result in the suspension of all deliveries on Purchaser’s account until financial responsibilities are satisfied and current. All amounts due to Seller are payable based upon the payment terms granted to Purchaser by Seller. Delinquent amounts shall accrue interest at the higher of 18% per annum or maximum statutory rate. Purchaser shall pay Seller a service charge of $35.00 for each check returned by Purchaser’s bank. Seller’s policy is that no deliveries will be made until any returned check and the related charges are paid in full. Failure to comply with said policy could result in a “Cash Only” payment status for future deliveries. Should the Purchaser’s account be turned over to an attorney or other agency for collection, should suit be brought on same, and/or should the same be collected through any judicial proceeding, Purchaser shall pay all reasonable attorney’s retain fees and court costs incurred by Seller. Interest, attorneys’ fees and costs of collection shall be considered sums owing in connection with the transactions under the Perishable Agricultural Commodities Act, 7 U.S.C. 499a et seq. This application and all transactions between Applicant and Brothers shall be governed by and interpreted in accordance with federal law where applicable and with the laws and decisions of the state of Texas. “Applicant” hereby waives any right that may exist to transfer or change venue of any litigation filed in such courts. Jurisdiction and venue for all non-federal court proceedings shall be in Dallas County, Texas. Purchaser shall notify Seller by certified mail of any changes in ownership of Purchaser. Purchaser authorizes Seller to investigate all references relating to the credit and financial responsibility of Purchaser. Purchaser certifies to Seller that all information furnished for the purpose of obtaining credit from Seller is true, correct, and complete in all material respects, and the information is being furnished to Brothers for the purpose of inducing Brothers to extend credit to Applicant, and understands Brothers intends to rely upon such information. Any reproduction of this Agreement by reliable means will be considered an original of this document. If this Application is not fully approved or if any other adverse action is taken with respect to Applicant’s request for credit terms with Brothers, Applicant has the right to request a statement of specific reason(s) for such action within sixty (60) days of Brothers notification of such adverse action; which statement shall be provided within thirty (30) days of said request. The Federal Equal Credit Opportunity Act prohibits creditors from discrimination against credit applicants on the basis of race, color, religion, national origin, sex, marital status, or age (provided the applicant has legal capacity to enter into a binding contract). The entire outstanding balance due to Brothers on all invoices shall become due in full immediately upon default in the payment of any invoice. All open credits and overpayments not claimed within 90 days from the posting date will automatically be removed from our accounting system. If such credits and overpayments are not claimed within the 90 day period, such will be considered abandoned, and no reimbursement will be issued. Applicant understands and agrees to be bound by the above and foregoing terms and conditions. All purchases by Applicant from Brothers will be made in accordance with the Terms and Conditions of this Application and any other documents evidencing Applicant’s obligations to Brothers, all of which are incorporated herein. Applicant understands that Brothers will retain this Application whether or not credit terms are extended to Applicant. "Purchaser"Name First Last Title Date Month Day Year Signature Personal Credit InformationAuthorization to Obtain Personal Credit Information in Compliance with the Fair Credit Reporting Act The undersigned hereby consents to Brothers use of non-business consumer credit reports in order to evaluate the credit worthiness of the undersigned as principal, proprietor, and/or guarantor in connection with the extension of business credit as contemplated by this credit application. The undersigned hereby authorizes Brothers to utilize business and/or consumer credit reporting agencies from time to time in connection with the extension or continuation of the business credit represented by this credit application. The undersigned as (an) individual(s) hereby knowingly consent(s) to the use of such credit report consistent with the Federal Fair Credit Report Act, 15 USC 1681 et seq.Name First Last Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Social Security Number Date Month Day Year Signature This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. CommentsThis field is for validation purposes and should be left unchanged.