Credit Application Credit Application Please fill out the information below and we will be in contact with you shortly. Thank you! Step 1 of 6 16% Name First Last Email Business Name* Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Is this the same as your shipping address?YesNoDo you have a Kelsan Sales Representative?YesNoAP Contact InformationName First Last Email PhoneBuyers Contact InformationName First Last Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Business Entity TypeEntity Type Corporation Retail Franchisee Hotel Member of Chain Sole Proprietorship Partnership Non-Profit Wholesale Church Limited Liability Comp Janitorial/Cleaning Services Other Trade ReferencesReference 1Reference 1-Name* First Last Reference 1-Phone*Reference 2Reference 2-Name* First Last Reference 2-Phone*Reference 3Reference 3-Name First Last Reference 3-Phone SECTION IVAnticipated Monthly PurchasesTerms Requested COD Credit Card Net 15 Net 30 Other If requesting credit card terms, a customer service rep. will reach out via phone to collect credit card information. If requesting extended terms beyond Net 30 provide contact information for Controller/AP:Name First Last PhonePurchase Order Required? Yes No Back Order Allowed? Yes No Priced Delivery Ticket? Yes No Substitutions Allowed? Yes No Sales Tax Exempt? Yes No If yes, copy of certificate must be submitted. Special InstructionsAny Time or Days Deliveries Cannot Be Made? Terms and ConditionsApplicant hereby affirms that the information provided on this credit application is true and complete to the best of their knowledge and applicant authorizes Kelsan to contact and verify all references. Any falsified information may result in rescinding of credit. Applicant agrees to pay all invoices in full according to the credit term provided. Applicant agrees that Kelsan shall charge a late charge of 7.5% on all delinquent balances. In the event of default, applicant agrees to pay collection costs up to 30%, reasonable attorney fees, and all court costs. Venue for all transactions shall be the State of Tennessee with jurisdiction in Knox County, Tennessee. Name First Last Date Date Format: MM slash DD slash YYYY Signature Continuing Personal GuarantyIn consideration of Seller’s agreement to extend credit to Applicant, as identified in Section I of this credit application, the undersigned individual(s) personally guarantee to Seller the payment of any and all current and/or future obligations owed by Applicant to Seller, any sums which may be advanced under application, or any other extension by Seller to Applicant. Applicant further agrees to that in the event of default, Seller shall charge and Applicant agrees to pay collection fees up to 30%, reasonable attorney fees, and all court costs. Venue for all transactions shall be the State of Tennessee with jurisdiction in Knox County, Tennessee. 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