Thank you for considering EnviroMix technology.
Account Info.

Business Name:
Contact Person:
City:
Shipping Address:
Mailing Address:
Postal Code:
Phone:
Fax:
Email:
Website:

Business Type

Limited Company Partnership Proprietership

Registered Legal Name:
Nature of Business:
Related Companies:
How long in business:
How long at present location:
Requested Credit Amount (Dollars):
Requested Terms:

Bank References

Bank:
Contact:
Phone:
Address:

Principals

Name:
Title:
Phone:
Name2:
Title2:
Phone2:
Name3:
Title3:
Phone3:

Business References (Current Only)

Name:
Phone:
Address:
Name2:
Phone2:
Address2:
Name3:
Phone3:
Address3:

I / We hereby request to establish credit privileges with EnviroMix and agree to pay for all purchases in accordance with the above terms of sale. I /We further agree to pay a service charge on any amounts past due calculated at 2% per month (26.8% per annum).

I / We certify the above information to be correct. Further, I / We authorize EnviroMix to obtain credit reports or other information as deemed necessary for establishing the requested credit account.