Commercial Credit Application

770 N High School Road, Indianapolis, IN 46214

PHONE: (800) 525-0272
COMMERCIAL CREDIT APPLICATION
ALL INFORMATION WILL BE TREATED IN A CONFIDENTIAL MANNER.
CREDIT AMOUNT REQUESTED:*
ENTITY TAX ID:*
For Sole Proprietorship, enter SSN. Other entities provide TID.
ENTITY NAME:*
PARENT COMPANY NAME:
IS GROSS ANNUAL REVENUE LESS THAN $25 MILLION?*

YESNO
YEARS IN OPERATION:
PHONE:*
EMAIL ADDRESS:*
example@example.com
BILLING ADDRESS:*

STREET ADDRESS

Street Address Line 2

CITY/STATE/ZIPState / Province

Postal / Zip Code
IF LESS THAN 3 YEARS AT CURRENT ADDRESS:

PREVIOUS STREET ADDRESS

Street Address Line 2

CITY/STATE/ZIPState / Province

Postal / Zip Code

APPLICANT / OWNERSHIP INFORMATION
APPLICANT / OWNER 1
NAME:*
Phone Number:*
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
TITLE:*
SSN:*
APPLICANT / OWNER 2
NAME:
Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
TITLE:
SSN:
APPLICANT / OWNER 3
NAME:
Phone Number:
Please enter a valid phone number.
Date of Birth:

MonthDayYear
Date
TITLE:
SSN:

TAX EXEMPTION INFORMATION
WILL YOU CLAIM ANY TAX EXEMPTION? PLEASE COMPLETE THE STATE RELATED EXEMPTION FORM AND ATTACH AT THE END OF THE APPLICATION.

YESNO
IF TAX EXMEMPT, ENTER TAX EXEMPT #:

BANKING REFERENCE
NAME OF BANKING INSTITUTION:
BANK ADDRESS:
NAME ON BANK ACCOUNT:
BANK PHONE:

AUTHORIZATION / APPROVALS

BUSINESS ENTITY, CORPORATION, LLC, OR PARTNERSHIP, PLEASE COMPLETE THIS SECTION.
WHO IS AUTHORIZED TO USE/ORDER FOR THIS ACCOUNT?*
AUTHORIZED USER PHONE:*
WILL A PURCHASE ORDER BE REQUIRED?*

YESNO
NAME OF ACCOUNTS PAYABLE MANAGER:
ACCOUNTS PAYABLE MANAGER EMAIL:
example@example.com
DOES ANY PRINCIPLE OWNER OF THIS COMPANY HAVE AN OWNERSHIP INTEREST IN ANY ENTITY THAT HAS A CREDIT ACCOUNT WITH KEYSTONE?*

YESNO
WHAT BUSINESS NAMES AND ACCOUNT NUMBERS?*

TRADE REFERENCES

PLEASE PROVIDE TWO TRADE REFERENCES OR UPLOAD A TRADE REFERENCE SHEET AND FINANCIALS.
(1) REFERENCE NAME:*
(2) REFERENCE NAME:
TYPE OF ACCOUNT:*
TYPE OF ACCOUNT:
LINE OF CREDIT / LIMIT:*
LINE OF CREDIT / LIMIT:
CURRENT BALANCE:*
CURRENT BALANCE:
CREDIT REFERENCE PHONE NUMBER:*
CREDIT REFERENCE PHONE NUMBER:
CREDIT REFERENCE EMAIL ADDRESS:*
example@example.com
CREDIT REFERENCE EMAIL ADDRESS:
example@example.com

PLEASE READ LEGAL TERMS BELOW. TERMS APPLY TO ALL ACCOUNTS. PLEASE SIGN AS APPROPRIATE.

Everything I have stated in this application or information that l have submitted with this application is accurate and true. If Keystone Cooperative, Inc. receives an insufficient funds check from the account holder, and/or as a condition of establishing credit, the following applies. I/We agree to pay the balance due and in addition all applicable FINANCE CHARGES which I/we hereby agree to pay in accordance to all terms and conditions in which I/we are notified from time to time, including but not limited to periodic statements sent to me setting forth the outstanding obligations I/we have to you. All parties agree the laws of the State of Indiana will apply to any dispute regarding this credit application on any amount owed on a Keystone account. I/We hereby agree to pay all attorney fees and court costs if this account is referred to attorneys for collection, without relief from valuation and appraisement laws. In accordance with Article 9 Section 402 of the UCC Code, the buyer further grants to seller a security interest in buyer’s equipment, contract rights, inventories, receivables and proceeds of sales as collateral to secure the buyer’s performance of all obligations. I/we hereby acknowledge Keystone may run a lien search for the entity or individual applying for credit. The applicant further authorizes Keystone to file a financing statement without applicant’s signature. A 1.75% finance charge will be added monthly to all past due balances. This is an annual rate of 21%. By signing, I authorize Keystone to investigate my credit record and report to proper persons and bureaus my performance of this agreement and to answer any questions about their credit experience with me. I authorize Keystone to release this application to my bank in order to obtain a bank reference. See future billing statements for important data.
*If a Business Entity requesting credit has less than $25 million in gross sales in the prior year, a personal guarantor will be required. Please indicate the name of the personal guarantor.

*Please read carefully: By signing as Personal Guarantor I am agreeing to be personally responsible for payment of all amounts billed on the accounts established on this credit application.
NAME OF 1ST PERSONAL GUARANTOR:*
NAME OF 2ND PERSONAL GUARANTOR:
PERSONAL GUARANTOR TITLE:
PERSONAL GUARANTOR TITLE:
SOCIAL SECURITY NUMBER OF GUARANTOR:*
SOCIAL SECURITY NUMBER OF GUARANTOR:
DATE OF BIRTH:*

MonthDayYear
Date
DATE OF BIRTH:

MonthDayYear
Date
SIGNATURE:*

Clear
SIGNATURE:

Clear
DATE:*

MonthDayYear
Date
DATE:

MonthDayYear
Date
Please submit a copy of your most recent financials for the business entity.*

FINANCIALS ENCLOSED
UPLOAD FINANCIALS:

Cancelof
Application will not be processed without signature and legibly printed name. Incomplete applications will be returned. Signature indicates you have read and agree to all terms and conditions.
APPLICANT 1 NAME:*
APPLICANT 1 TITLE:*
APPLICANT 1 SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
APPLICANT 2 NAME:*
APPLICANT 2 TITLE:*
APPLICANT 2 SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
APPLICANT 3 NAME:*
APPLICANT 3 TITLE:*
APPLICANT 3 SIGNATURE:*

Clear
DATE:*

MonthDayYear
Date
ATTACH OTHER DOCUMENTS:

Cancelof
NO REPLY
example@example.com
Should be Empty: