Eureka Oxygen Credit Application

HOW DID YOU HEAR ABOUT US:

Applicant Name or Business Name:*

DBA (If Applicable)

Billing Address*

Street Address Physical Address (If Different From Above): City State ZIP Code

Is The Delivery Address Different From Above*

Yes
No

Delivery Address If Different From Billing

(Location Where Eureka Oxygen Property Will Be Stored) City State ZIP Code

Main Contact Phone*

Cell - If Different than Main

Fax

Email*

Would you like your invoices and statements emailed?

yes
no

Invoice & Statement Email Address

Terms Of Service
I acknowledge, all deposits and/or refunds will be issued by check, regardless of original form of payment and will be made payable to the order of the “Applicant Name or Business Name” listed above. No Exceptions.
Short-Term Accounts (Available at Eureka Oxygen ONLY): I acknowledge/agree to pay $1.00 per day, per item for each day after seven (7) days at no charge

Agree to Terms Of Service*

Yes

To Be Completed For Business Credit ONLY

Type of business (Check One)*

Individual
Partnership
Corporation
Government

Owners/Officers

Name of Owner/Officer 1

Social Security # - of Owner/Officer 1

Title of Owner/Officer 1

Address of Owner/Officer 1

Phone of Owner/Officer 1

Do you have more owners/officers to enter?

Yes
No

Has Business or Any Owner/Officer Ever Filed Bankruptcy

Yes
No

Please Explain the Bankruptcy

Please Fill Out Additional Officers/Owners

Officer/Owner - 2

Name of Owner/Officer 2

Social Security Number Owner/Officer 2

Title of Owner/Officer 2

Address of Owner/Officer 2

Phone of Owner/Officer 2

Officer/Owner - 3

Name of Owner/Officer 3

Social Security Owner/Officer 3

Title Owner/Officer 3

Address Owner/Officer 3

Phone Owner/Officer 3

Business Details

Nature of Business*

Tax ID #

Contractor License #

Resale Permit#

Complete CA Resale Form, BOE-230

How Long in Business

How Long Under Current Ownership

Bookkeeper-A/P Contact Name

Bookkeeper-A/P Phone*

Bookkeeper-A/P Email

Bank Name

Bank Phone

Bank Address

Bank Account #

Have you been in business for 3 or more years?

Yes
No

Trade Suppliers/Credit References

– If you’ve been in business for 3 or more years, please provide trade references and their fax numbers. Otherwise, please provide a social security number in order to be eligible for a Net 30 day account.
PLEASE INCLUDE A FAX NUMBER OR EMAIL ADDRESS! THANK YOU

Credit Reference 1

Name of credit Reference 1

Phone of credit Reference 1

Address of credit Reference 1

Please select and provide one of the following for Credit Reference 1*

Email
Fax

Email credit Reference 1

Fax of credit Reference 1

Credit Reference 2

Name of credit Reference 2

Phone credit Reference 2

Address credit Reference 2

Please select and provide one of the following for Credit Reference 2*

Email
Fax

Email Credit Reference 2

Fax credit Reference 2

Credit Reference 3

Name credit Reference 3

Phone credit Reference 3

Address credit Reference 3

Please select and provide one of the following for Credit Reference 3*

Email
Fax

Email Credit Reference 3

Fax credit Reference 3

Credit Reference 4

Name credit Reference 4

Phone credit Reference 4

Address credit Reference 4

Please select and provide one of the following for Credit Reference 4*

Email
Fax

Email Credit Reference 4

Fax credit Reference 4

To Be Completed For All Account Types

AUTHORIZED USER(S)
An Authorized User is a person you authorize to use your account at Eureka Oxygen, Co. You will be liable for all the transactions. the Authorized User(s) incurs on your Account. You, as the undersigned Guarantor, agree to be responsible for all the transactions the Authorized User(s) makes on your Account.

Authorized User Name 2*

First Last

Authorized User Name 1*

First Last

Do you need to submit more than 2 names for Account Authorization?

Yes
No

Additional Names for Account Authorized

Please list additional names here

To cancel or remove the authority of an Authorized User, please call our office and inform us of the cancellation AND in addition, deliver to us, an updated Authorized User form. The terms and conditions of your Account will remain the same and the cancellation will become effective once we confirm the cancellation and update our records according to your written request.

Required

By initialing below, I am acknowledging that I have read, understand, and agree to the following statements:

I acknowledge all deposits and/or refunds will be issued by check, regardless of the original form of payment, and will be made payable to the order of the “Applicant Name or Business Name” listed on page 1 of this application. No Exceptions.

Initials acknowledgement refunds*

I acknowledge that all cylinders and dry ice bins will be subject to daily rent and any unpaid balance will be deducted from my deposit.

Initials acknowledgement unpaid balance*

Short-Term Accounts (Available at Eureka Oxygen ONLY): I acknowledge and agree to pay $1.00 per day, per item for each day after seven (7) days at no charge.

Initials acknowledgement short-term*

Personal Guarantee
MUST Be Completed To Be Considered For All Account Types (COD/Short-Term, Personal Credit & Business Credit) Authorization is hereby granted to Eureka Oxygen Company, Inc. to obtain a standard factual data credit report through a credit reporting agency chosen by Eureka Oxygen Company, Inc. My signature below authorizes the release to the credit reporting agency a copy of my credit application, and authorizes the credit reporting agency to obtain information regarding my employment, savings accounts, and outstanding credit accounts (mortgages, auto loans, personal loans, charge cards, credit unions, etc.). Authorization is further granted to the reporting agency to use a photo static reproduction of this authorization, if necessary, to obtain any information regarding the above mentioned information. Under the Fair Credit Reporting Act, applicant/s have a right to know and to receive a free copy of the information contained in their credit file at the consumer reporting agency. If credit is denied, applicant/s may request a copy, in writing, no later than 60 days after they receive notification. In consideration of credit being extended by Eureka Oxygen Company DBA: Ukiah Oxygen, Petaluma Oxygen & Lake County Welders Supply to the above named applicant for merchandise to be purchased whether applicant be an individual or individuals, a proprietorship, a partnership, a corporation, or other entity, the undersigned guarantor or guarantors each hereby contract and guarantee to Eureka Oxygen Company the faithful payment, when due, of all accounts of said applicant including applicant’s authorized agent(s) and or employees for purchases made on behalf of applicant as of the date of this application. The undersigned guarantor or guarantors each hereby express waive all notice of acceptance of this guarantee, notice of extension of credit to applicant, presentment, and demand for payment on applicant, protest and notice to undersigned guarantor or guarantors of dishonor or default by applicant or with respect to any security held by Eureka Oxygen Company, extension of time of payment to applicant, acceptance of partial payment or partial compromise, all other notices to which the undersigned guarantor or guarantors might otherwise be entitled and demand for payment under this guarantee. Any revocation of this guarantee shall be in writing and delivered to Eureka Oxygen Company. This Personal Guarantee can only be modified in writing and signed by both parties. Applicant agrees to pay any collection cost incurred to collect the unpaid balance, including but not limited to interest on the unpaid balance as allowed by the state law and any reasonable attorney fees incurred. The undersigned as an inducement to grant credit warrants that the information submitted is true and correct. Eureka Oxygen Company is authorized to investigate the credit references and verify the applicant information as listed above. By signing below, applicant declares that the foregoing information is true and correct. Upon acceptance of credit being extended, applicant will be entered into the above personal guarantee contract. Payment history may or may not at some time be reported to a credit bureau. Applicant agrees to pay for purchases in accordance with account billing terms of net 30 days (balance on account due in full 30 days from purchase date) and further agree to pay service charges of 1½% per month (18% annually) on balances not paid within billing terms. If you have any questions regarding our personal guarantee policy, please call our office at (707) 443-2228.

Acknowledge Personal Guarantee*

Please enter your name and date.

Date

Email

This field is for validation purposes and should be left unchanged.

Please, don’t hesitate to call our main office at 707-443-2228 if you have any questions

Cash Only (COD)/Short-Term

Credit Application: Cash Only (COD)/Short-Term

To Be Completed For All Account Types

How Payments Are Applied

Required

Personal Guarantee

Personal Credit

– provide a social security number to be eligible for a Net 30 day account.

Personal Credit

To Be Completed For Personal Credit ONLY

Please Provide Joint Application Information

To Be Completed For All Accounts

APPLICATION OF PAYMENTS

Required

Personal Guarantee

Business Credit

Business Credit

To Be Completed For Business Credit ONLY

Please Fill Out Additional Officers/Owners

Officer/Owner - 2

Officer/Owner - 3

Business Details

Trade Suppliers/Credit References

Credit Reference 1

Credit Reference 2

Credit Reference 3

Credit Reference 4

To Be Completed For All Account Types

Required

Personal Guarantee

Safety Products

Cylinder Gases

Fire Suppression

Don't Be Shy