Download credit account application form

CREDIT ACCOUNT APPLICATION FORM
PRIVATE & CONFIDENTIAL
We …………………………………………… (hereafter called the Distributor) apply for Credit
Facilities with High Chem Essentials Ltd (hereinafter called the Supplier) and agree to the
following conditions:
1. That the Supplier may apply to our Bankers or the Traders for reference and this
application is therefore signed by our Authorized Bank Signatories.
2. That all accounts are due for payment 30 days after issue of invoice unless otherwise
agreed in writing.
3. That should the Distributor fail to observe the terms granted by the Supplier, our credit
facilities will immediately be withdrawn and only reinstated at the Supplier’s sole
discretion.
4. That the Distributor agrees to pay charges on overdue balances at the rate of 2% per
month.
5. That the Distributor agrees to pay all and any legal charges that may result form the
Supplier having to take legal action to recover any debt due to the Supplier.
6. In the event of any account being handed over to Solicitors, after settlement, all
subsequent transaction shall be for cash or guaranteed Bankers Cheque only.
7. The Distributor agrees to supply all information on the attached form as follows:
Name: ……………………………….
Name: ……………………………….
Signature: …………………………….
Signature: ……………………………..
Designation: ………………………….
Designation: ………………………….
Date of Application: ………………………………………………..
Please note that the granting of credit is purely at the Supplier’s discretion.
All details must be completed or the application may not be considered.
8)
Bankers:
Name
_________________
_________________
_________________
_________________
Account No.
__________________
__________________
__________________
__________________
Address
______________
______________
______________
______________
Tel. No.
Physical Address
_________________ ______________
_________________ ______________
__________________
__________________
______________
______________
b) Name
Tel. No.
Physical Address
__________________
__________________
______________
______________
9)
Branch
______________
______________
______________
______________
Trade Reference:
a) Name
Postal Address
Postal Address
_________________ ______________
_________________ ______________
10) What value of credit do you anticipate requiring on monthly basis?
Kshs. ____________________________________________________________________
Yours sincerely,
________________________
AUTHORISED SIGNATURE
DISTRIBUTOR’S COMPANY NAME: ____________________________________________
ADDRESS: __________________________________________________________________
RUBBER STAMP: ____________________________________________________________
11. DISTRIBUTOR INFORMATION:
a. Name of Company: __________________________________________________________
b. Type of Company (Private/Public/Unlimited) _____________________________________
c. Date of incorporation: ____________________ d. Incorporation No. ___________________
e. Postal Address: _____________________________________________________________
f. Email Address: _____________________________________________________________
g. Physical Address of Company: ________________________________________________
h. Name of Managing Person: ___________________________________________________
i. Designation: _______________________________________________________________
j. Telephone Numbers: _________________________________________________________
k. Associated / Subsidiary Companies:
NAME:
ADDRESS:
________________________________
___________________________________
________________________________
___________________________________
l. DIRECTORS’ NAMES
NATIONALITY
ADDRESS
______________________
___________________
______________________
______________________
___________________
______________________
m. Issued and paid up capital as per current Balance Sheet, ____________________________
n. What Business Activity are you engaged in? _____________________________________
o. Number of Employees _______________________________________________________
p. Number of years in Business __________________________________________________
q. Details of Insurance Cover over stock i.e. Cover issued by __________________________
__________________________________________________________________________
Insurance Cover value _______________________________________________________
Insurance Cover valid up to ___________________________________________________
12. PERSONAL GUARANTEE:
By signing the agreement constituted herein, the Director’s guarantee that if the distributor
defaults in payment of the monies due to HighChem Veterinary Ltd, they shall be
personally and severally liable to pay HighChem Veterinary Ltd as if they were the
principal debtor.
Dated this _____________________________ day of _______________________ , 2003
Signature ______________________________ Signature __________________________
Name _________________________________ Name _____________________________
Designation ____________________________ Designation ________________________
Company Rubber Stamp: ________________________________________________________
13. SUPPLIER COMMITMENTS:
1. To supply all products in schedule 1 and to update this schedule to the Distributor
regularly as the portfolios changes from time to time.
2. To supply a price structure for all our products in schedule 1.
3. Protect the Distributor against unfair competition in his region of operation.
4. To promote all marketing activities that relate to increased business in the area of
Distributor operations.
14. DISTRIBUTOR COMMITMENTS:
1. To provide all information that may impede on the business here entered into.
2. To put under confidential cover any matters relating to business that is not of public
consumption.
3. To use all within the Distributor’s control to promote the products in the area of
operation.
4. To maintain professionalism in all matters of sales, distribution and marketing within the
laws that govern the Kenyan Agricultural business.
15. FOR OFFICIAL USE ONLY:
Recommendation Remarks:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Application approved for a limit of Kshs. ____________________________________________
Application Recommended by: ____________________________________________________
Approving Authority: ________________________________ Signature: __________________
Date: ________________________________________________________________________