Town & Country Foods

P.O. Box 17263

Beverly Hills
CA 90209-3263
town-countryfoods@sbcglobal.net
Tel: 310-622-0410 Fax: 818-475-5130

CASH APPLICATION (C.O.D) $300.00 D/O

NO APPLICATION WILL BE PROCESSED UNTIL COMPLETED AND SIGNED.

Corporate Name ______________________________ Doing business as _________________________

Type of business ______________________________ Subsidiary of _____________________________
Mailing Address _______________________________________________________________________
Delivery Address ______________________________________________________________________
Business Telephone # __________________________ Business Fax _____________________________
Year Organized _______________________________ Years at this address _______________________
Check One Proprietorship ______________ Partnership ____________ Corporation __________
Franchise Tax # _______________________________ State Liquor License # _____________________

Owners, Partners or Corporate Officers

Name Title Home Address Driver Licence S.S. #
_____________________ __________ __________________________ _________________ _______
_____________________ __________ __________________________ _________________ _______
_____________________ __________ __________________________ _________________ _______
_____________________ __________ __________________________ _________________ _______

Banking Information
Bank Name ____________________________________ Account # _____________________________
Bank Address _________________________________________________________________________
Bank Contact __________________________________ Bank Telephone _________________________
Other Bank Accounts ___________________________________________________________________
I HEREBY AUTHORIZE THE ABOVE NAMED BANK TO RELEASE MY BANKING CREDIT
INFORMATION TO TOWN & COUNTRY FOODS.
Signature ______________________________________________ Date _____________________________
Signature ______________________________________________ Date _____________________________
 Town & Country Foods
P.O. Box 17263
Beverly Hills
CA 90209-3263
town-countryfoods@sbcglobal.net
Tel: 310-622-0410 Fax: 818-475-5130

TRADE REFERENCES
Account # Name Address City Phone Number
___________ ____________________ __________________________ __________ ______________
___________ ____________________ __________________________ __________ ______________
___________ ____________________ __________________________ __________ ______________
___________ ____________________ __________________________ __________ ______________
___________ ____________________ __________________________ __________ ______________
Has this business filed for Bankruptcy within the last seven years ? _____ If so, was it a chapter 11or 7 ? ____
Has this business ever been sued for unpaid supplier bills ? ______ If yes, explain ______________________

Terms Of Sale:
By accepting delivery of goods and supplies and/or by signing a copy hereof, buyer agrees that:
1. This invoice is delinquent if not paid prior to the last day of the month following the delivery.
2. Delinquent invoices are subject to a monthly service charge of a 1 percent per month.
3. Any claim for damaged or defective merchandise must be made within three days after delivery.
4. In the event that it is necessary to comment an action at law for the collection of any past due invoice,
buyer hereby agrees to bear all court costs plus attorney fees of 25% of the unpaid balance owed.
5. Applicant hereby warrants that the above statements made are true and correct and made for the sole
purpose of obtaining a line of credit.
6. Applicant has read and fully understood all of the provisions contained hereinabove and agrees to all
terms as set forth in paragraphs 1 through 4.
7. I / We agree to sign the personal guarantee below.

Authorized Signature(s)
1 ______________________________ Title ______________________________ Date _________________
2 ______________________________ Title ______________________________ Date _________________
3 ______________________________ Title ______________________________ Date _________________
THE UNDERSIGNED JOINTLY AND SEVERALLY PERSONALLY GUARANTEE THE PAYMENT OF
ALL AMOUNTS INCURERED BY THE COMPANY SET FORTH ABOVE.
Signature ______________________________________________ Date _____________________________
Signature ______________________________________________ Date _____________________________