V1, Revised 05/2019

Central Indiana Hardware, Inc.

Credit Application

Company Information

Legal Company Name:Doing Business As (DBA): Primary Business of Company: Federal Tax ID #: Business Structure: State of Incorporation: Date of Incorporation: Pending Lawsuits Against Company:

Billing Preference (Mail or Email): Email Address:

Billing Address: City: State: Zip Code: Telephone Number:

Shipping Address: City: State: Zip Code: Telephone Number:

Return Completed / Signed Form to:

cihcreditapplication@cih-inc.com

For Internal Use Only

Sales Rep:

Date:

Amount:

Yes No

Mail Email

If Tax Exempt , please provide a State issued exemption certificate

Payables Contact Name:Email Address:

Purchasing Contact Name: Email Address:

If yes, please elaborate: Purchases will be: Taxable Tax Exempt

V1, Revised 05/2019

Name: Title: Address (*): City (*): State (*): Zip Code (*): Telephone Number (*): SSN (*):

Name: Title: Address (*): City (*): State (*): Zip Code (*): Telephone Number (*): SSN (*):

Bank Information Name of Bank: Type of Account: Account Number: Primary Bank Contact: Primary Contact Email Address: Primary Contact Telephone Number:

Name of Bank: Type of Account: Account Number: Primary Bank Contact: Primary Contact Email Address: Primary Contact Telephone Number:

Officers, Proprietor or Partners (* = Home Address and SSN requested if Proprietorship or Partnership)

V1, Revised 05/2019

Business Name: Account Number: City: State: Primary Financial Contact: Primary Contact Email Address: Fax Number:

Business Name: Account Number: City: State: Primary Financial Contact: Primary Contact Email Address: Fax Number:

Business Name: Account Number: City: State: Primary Financial Contact: Primary Contact Email Address: Fax Number:

Business Name: Account Number: City: State: Primary Financial Contact: Primary Contact Email Address: Fax Number:

Business Name: Account Number: City: State: Primary Financial Contact: Primary Contact Email Address: Fax Number:

Credit References

V1, Revised 05/2019

Terms and Conditions

I hereby warrant that the above information is true and correct, and is furnished for the purpose of obtaining credit for the company listed (hereafter referred to as Customer). I hereby agree that Central Indiana Hardware and or its affiliated branches (hereafter referred to as CIH) may investigate the company's listed credit record and that if an account is opened, CIH may furnish information regarding this account to credit reporting agencies and others who may properly request such information. The company listed authorizes any and all agencies listed on this application as a credit reference to release information about our company’s credit to CIH. By signing this application, the company promises to pay any charges to their account according to the credit terms issued to them by CIH. The undersigned company hereby applies to CIH for credit for all purchases of material, services and / or labor from CIH. Upon credit approval, CIH shall provide standard terms of NET 30 unless otherwise approved by CIH and in consideration for an extension of such credit, the company agrees to fully pay all debts due CIH. Should Customer fail to pay in a timely manner, CIH can or shall assess interest on such past due amounts at the rate of eighteen percent (18%) per annum from the due date until fully paid, plus all reasonable attorney fees, third party collection fees, court costs or other expenses CIH incurs in its collection efforts. The parties agree that any litigation between the parties shall be commenced in the state of Indiana, in the courts of Marion County, Indiana and hereby waive any and all objections to Indiana Jurisdiction and venue in Marion County. CIH may accept this Credit Application by invoicing customer for purchases of materials, services and / or labor in lieu of requiring payment at order placement. Customer agrees that it will be bound by the terms of this Agreement upon the extension of such credit to the Customer by CIH. Any strike outs of this agreement will make the credit application null and void.

Business Name:

Authorized Representative:

Signature: orElectronic Signature:

Title: Date: