Credit Application - Workflow

For the purpose of obtaining merchandise from Hercules Industries, Inc ('Hercules") on credit, the following statement is made intending that Hercules should rely on same as correct.

Applicant Name*

First Name

Last Name

Applicant Email*

Applicant Phone*

Company Name*

Do you have a Physical Business Address and/or P.O. Box?*

Physical Business Address P.O. Box

Physical Business Address*

Address Line 1

Address Line 2

City

State

ZIP Code

P.O Box*

City*

State*

Zip Code*

Business Type*

Corporation Limited Liability Company Partnership Sole Proprietor / Individual

Owner Name *

Owner Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

President Name *

President Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Vice President Name *

Vice President Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Treasurer Name*

Treasurer Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Secretary Name*

Secretary Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Managing Member Name *

Managing Member Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Member Name *

Member Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Partner Name*

Partner Residence Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Partner Name

Partner Residence Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone

Are you incorporated?*

Yes No

Date Business Incorporated*

Have you conducted business under any other name?*

Yes No

Please state name(s) and date(s) used *

Bank Name *

Branch/Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Bank Contact

Bank Phone*

Checking Account #*

For maximum credit, please attach your most recent financial statement

No File Chosen

File uploads may not work on some mobile devices.

Have you and/or officer of your company ever had a business failure? *

Yes No

Name of company and date*

Are purchases taxable?*

Yes No

Please furnish certificate*

No File Chosen

File uploads may not work on some mobile devices.

Would you like to receive electronic invoices? *

Yes No

Do you have an EPA Card?*

Yes No

EPA card is required by the Federal Government for each company to purchase refrigerant-bearing units from Hercules Industries

Please attach EPA Card

No File Chosen

File uploads may not work on some mobile devices.

Do you have a Mechanical License?*

Yes No

Please attach Mechanical License

No File Chosen

File uploads may not work on some mobile devices.

The Applicant certifies that the above information is true and correct and agrees to pay for all goods purchased in compliance with the terms of Hercules. Unless otherwise agreed to in writing, said terms are that all goods are to be paid in full within 30 days of invoice date. Should goods not be paid in full when due, any outstanding balance shall accrue interest at 1.5% per month (18% APR.). Should Hercules take any action to collect any amounts due, it shall be entitled to recover any outstanding balance, plus accrued interest, as well as, its reasonable attorney or collection agency fees and costs. Hercules and the Applicant agree that this contract is entered into at Denver, Colorado any and all monies due and payable to Hercules (and any of its divisions) are due and payable at Hercules, 1310 West Evans, Denver, Colorado 80223. This credit application shall be construed and interpreted by Colorado law and, in the event of a dispute, venue shall be proper in the City and County of Denver, Colorado at Hercules' option. All the undersigned, authorize Hercules to investigate credit background through credit agencies and references listed herein and for all other references to release any and all information at any time. The undersigned releases Hercules from all liabilities resulting from any information released or obtained.

NOTE: Application must be signed in two places before application will be processed.

By clicking this box, you are consenting to the use of your electronic signature as a valid acceptance and submittal of this credit application to Hercules Industries, Inc. (“Hercules”). Please know that in order to transact business with Hercules your consent to an electronic signature or transmission is not required and you may instead request and complete this credit application in a non-electronic form (which is also available) should you wish by calling our credit department at 303-937-1000 or sending an email to acctrec@hercmail.com. You may also subsequently elect to withdraw your acceptance of the use of your electronic signature at any time using the same methods to contact Hercules. Of course, should this election later be made, you will be asked to submit a new credit application in a non-electronic form prior to conducting any further business with Hercules. So that you are aware, Hercules will store your credit application electronically for as long as it is valid, and you continue to conduct business with Hercules. You can make a written request to Hercules for a copy of this credit application at any time should you wish, but also know that any transactions associated with the account can be accessed via the assigned web portal account at any time. As a final consideration, should you not transact any business with Hercules for a period of three (3) years, your credit application shall then be automatically electronically destroyed by Hercules.

Electronic Signature Consent*

I Agree I Do Not Agree

Full Name of Company *

Signature*

[clear]

Use your mouse or finger to draw your signature above

Date*

Print Name and Title*

Personal Guarantee

(IF A LIMITED LIABILITY COMPANY OR CORPORATION IS APPLYING FOR. CREDIT, THIS GUARANTEE MUST BE SIGNED BY A MEMBER(S)/CORPORATE OFFICER(S))

For and in consideration of selling any goods or materials to the above Applicant on the account or otherwise by Hercules, I hereby absolutely and unconditionally guarantee the credit account debt or obligation of the above named Applicant. This is a continuing guarantee and shall continue so long as credit is extended or the account, debt or obligation is open. I expressly waive notice of default, diligence, resort to security, any obligation to proceed against debtor or any other guarantor, and joinder of debtor or other guarantors. I further agree to pay all attorney's fees, and costs and other expenses incurred in enforcement of the underlying obligation and this guarantee and agree that in the event of litigation, suit may be brought in the City and County of Denver, Colorado.

By clicking this box, you are consenting to the use of your electronic signature as a valid acceptance and submittal of this credit application to Hercules Industries, Inc. (“Hercules”). Please know that in order to transact business with Hercules your consent to an electronic signature or transmission is not required and you may instead request and complete this credit application in a non-electronic form (which is also available) should you wish by calling our credit department at 303-937-1000 or sending an email to acctrec@hercmail.com. You may also subsequently elect to withdraw your acceptance of the use of your electronic signature at any time using the same methods to contact Hercules. Of course, should this election later be made, you will be asked to submit a new credit application in a non-electronic form prior to conducting any further business with Hercules. So that you are aware, Hercules will store your credit application electronically for as long as it is valid, and you continue to conduct business with Hercules. You can make a written request to Hercules for a copy of this credit application at any time should you wish, but also know that any transactions associated with the account can be accessed via the assigned web portal account at any time. As a final consideration, should you not transact any business with Hercules for a period of three (3) years, your credit application shall then be automatically electronically destroyed by Hercules.

Electronic Signature Consent*

I Agree I Do Not Agree

Guarantor Signature*

[clear]

Use your mouse or finger to draw your signature above

Social Security #*

Confirm *

Print Name *

Date*

Do you have any other guarantor?*

Yes No

By clicking this box, you are consenting to the use of your electronic signature as a valid acceptance and submittal of this credit application to Hercules Industries, Inc. (“Hercules”). Please know that in order to transact business with Hercules your consent to an electronic signature or transmission is not required and you may instead request and complete this credit application in a non-electronic form (which is also available) should you wish by calling our credit department at 303-937-1000 or sending an email to acctrec@hercmail.com. You may also subsequently elect to withdraw your acceptance of the use of your electronic signature at any time using the same methods to contact Hercules. Of course, should this election later be made, you will be asked to submit a new credit application in a non-electronic form prior to conducting any further business with Hercules. So that you are aware, Hercules will store your credit application electronically for as long as it is valid, and you continue to conduct business with Hercules. You can make a written request to Hercules for a copy of this credit application at any time should you wish, but also know that any transactions associated with the account can be accessed via the assigned web portal account at any time. As a final consideration, should you not transact any business with Hercules for a period of three (3) years, your credit application shall then be automatically electronically destroyed by Hercules.

Electronic Signature Consent*

I Agree I Do Not Agree

Guarantor Signature *

[clear]

Use your mouse or finger to draw your signature above

Social Security #*

Confirm *

Print Name*

Date*

THE SIGNATURE ON THIS CREDIT APPLICATION, IF TRANSMITTED BY FACSIMILE MACHINE OR EMAIL WILL BE ACCEPTABLE AND BINDING AS IF IT WERE THE ORIGINAL.

INFORMATION DISCLOSURE AUTHORIZATION

TO WHOM IT MAY CONCERN:

I/WE HEREBY AUTHORIZE YOU TO RELEASE FOR VERIFICATION PURPOSES INFORMATION REQUESTED CONCERNING:

Any information deemed necessary in connection with a consumer credit report for business purposes.
Trade references from any of the references listed below:

Credit References

Please list your current, major suppliers (at least 3). Give only those names you buy from on an open account.

Please do not list subcontractors or revolving credit accounts.

How would you like to provide credit references?*

Upload a Credit Reference File Type in this Online Form

File*

No File Chosen

File uploads may not work on some mobile devices.

(1) Account Number*

(1) Reference Name

First Name

Last Name

(1) Email

(1) Company*

(1) Address*

Address Line 1

Address Line 2

City

State

ZIP Code

(1) Phone*

(2) Account Number *

(2) Reference Name

First Name

Last Name

(2) Email

(2) Company*

(2) Address*

Address Line 1

Address Line 2

City

State

ZIP Code

(2) Phone *

(3) Account Number*

(3) Reference Name

First Name

Last Name

(3) Email

(3) Company*

(3) Address *

Address Line 1

Address Line 2

City

State

ZIP Code

(3) Phone *

(4) Account Number

(4) Reference Name

First Name

Last Name

(4) Email

(4) Company

(4) Address

Address Line 1

Address Line 2

City

State

ZIP Code

(4) Phone

THIS INFORMATION IS FOR CONFIDENTIAL USE IN COMPILING INFORMATION TO EXTEND CREDIT ON AN OPEN TERM AGREEMENT.

A PHOTOGRAPHIC, CARBON, OR FAXED COPY OF THIS AUTHORIZATION (BEING A COPY OF THE SIGNATURE(S) OF THE UNDERSIGNED) MAY BE DEEMED TO BE THE EQUIVALENT OF THE ORIGINAL AND MAY BE USED AS A DUPLICATE ORIGINAL.

YOUR PROMPT REPLY WILL BE GREATLY APPRECIATED. THANK YOU FOR YOUR COOPERATION.

By clicking this box, you are consenting to the use of your electronic signature as a valid acceptance and submittal of this credit application to Hercules Industries, Inc. (“Hercules”). Please know that in order to transact business with Hercules your consent to an electronic signature or transmission is not required and you may instead request and complete this credit application in a non-electronic form (which is also available) should you wish by calling our credit department at 303-937-1000 or sending an email to acctrec@hercmail.com. You may also subsequently elect to withdraw your acceptance of the use of your electronic signature at any time using the same methods to contact Hercules. Of course, should this election later be made, you will be asked to submit a new credit application in a non-electronic form prior to conducting any further business with Hercules. So that you are aware, Hercules will store your credit application electronically for as long as it is valid, and you continue to conduct business with Hercules. You can make a written request to Hercules for a copy of this credit application at any time should you wish, but also know that any transactions associated with the account can be accessed via the assigned web portal account at any time. As a final consideration, should you not transact any business with Hercules for a period of three (3) years, your credit application shall then be automatically electronically destroyed by Hercules.

Electronic Signature Consent*

I Agree I Do Not Agree

Company Name*

Date*

Signature*

[clear]

Use your mouse or finger to draw your signature above

Federal Tax ID #*

Principal*

First Name

Last Name

Principal Email*

Principal Phone

Accounts Payable*

First Name

Last Name

Accounts Payable Email*

Accounts Payable Phone*

Billing *

First Name

Last Name

Billing Email*

Billing Phone*

Sales

First Name

Last Name

Sales Email

Sales Phone

Purchasing

First Name

Last Name

Purchasing Email

Purchasing Phone

Preferred Communication

Text Message Email

Primary Hercules Industries Branch Location *

About how many people are currently employed at your company? *

How many states are you operating in?*

What describes your business best? *

Residential / New Construction Commercial Add on / Replacement Multifamily Ductfab Other (Plumbing, Electric, etc.)

If multiple answer apply, please choose the category that your business does the most volume in

If other, please explain:*

When do you need product or to make your first purchase?*

NOTE: Application must be signed before application will be processed.

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The signature on this application if transmitted via fax, email, or online will be acceptable and binding as if it were the original.

Customer ID:

Enter Customer ID*

Enter into Active Campaign

Entered?*

Yes No