Business Charge Application - Bear Ace Hardware

Elkhart Location
21826 SR 120
Elkhart, IN 46516
574-295-5806

LaGrange Location
1100 S Detroit St
LaGrange, IN 46761
260-585-8132

Ligonier Location
1352 Lincolnway S
Ligonier, IN 46767
260-894-3404

"*" indicates required fields

Application Information

The following information must be provided. It will be held in the strictest confidence.

Company Name*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone Number*

Fax Number

Years at this address*

Years in business*

Accounts Payable Contact*

First Last

Accounts Payable Email*

Do you require a purchase order?*

Yes

Type of Ownership*

Corporation

Partnership

Sole Proprietorship

Federal ID #

Social Security #

Tax Exempt*

Yes – Fill out Form ST-105

Resale*

Yes – Fill out the Certificate of Resale

Type of Business*

Ownership*

Name of Officer and Position

Complete Address

Phone

Bank Name*

Bank Address*

Street Address Address Line 2 City State ZIP Code

Bank Office or Department*

Bank Phone*

Business References*

Business Name

Complete Address

Phone

Fax

Comments

List any Comments and/or Names of Persons Authorized to Charge to the Account: (will be treated as Open Account otherwise). Please notify us of any changes to this list.

I/we certify that all the information on this form is correct. I/we fully understand your credit terms and agree to the proper payment in consideration of extended credit. Furthermore, I/we approve of your obtaining information from the above references and a credit report on my company or if not a corporation, a report on me/us personally. If you update, renew, or extend my line of credit, you may request a new report without notice.

Date*

Name*

First Last

Title*

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Name

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