Highland Home Credit Application

Highland Home 706 Richard Street

Credit Application (Application must be filled out completely and signed)

Springfield, TN 37172 Phone: 615-382-6818 Toll Free: 877-395-3473 www.conimar.com

Please tell us which Highland Home brand you are requesting credit for today: Highland Home

Conimar CounterArt

Bill-To

Tel#

Address

Fax#

City/State/Zip

A/P Fax#

County

AP Email Address

Taxable

Tax Exempt

Project Specific Exempt

(Copy of Certificate(s) REQUIRED)

(Copy of Certificate(s) REQUIRED)

Business Information

Type

Corporation

Partnership

Proprietorship

Processor

Manufacturing

Distributor

LLC

D&B # FEIN#

Business Description

State & Date of Incorporation

Principals – (Names and Titles of Owner/Partners/Officers)

Name Name

Title Title

*References (Please provide at least 3 Business Trade References in addition to 1 Banking Reference) Bank: Acct# Fax# Tel# Routing# (Bank Key 9 Digit): Type: Checking Savings Trade: Name City/State Phone/Fax# (Mandatory) 1) / 2) / 3) /

Credit Limit Requested

$

Anticipated Annual Volume

$

I, the undersigned, am an authorized representative of the company stated above, and acknowledge that all information provided to the Seller-Creditor is truthful and accurate. Seller-Creditor intends to rely upon the information and statements provided herein to evaluate credit worthiness. Seller-Creditor maintains the right to establish or refuse terms. Seller-Creditor is authorized to check and confirm Applicant’s Credit History including Trade and Bank References. Past due amounts are subject to interest charges according to Conimar Group terms and conditions and Applicant agrees to pay all costs of collection, including expenses, fees, and all reasonable attorney’s fees and court costs, which may be incurred by all Conimar divisions and subsidiaries of Conimar. Conimar states that all court proceedings will take place in Florida

Authorized Signature (Must be Officer of the Company)

Title

Date

***Information provided is strictly confidential and will be used for our sole purpose***