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Diversified Foods, Incorporated
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NEW CUSTOMER CREDIT APPLICATION & AGREEMENT
PHONE (504) 831-6651 FAX (504) 831-8288
**INSTRUCTIONS: Please print or type. Fill in all spaces and complete by signing where indicated. If a corporation, the signature must be that of an officer. If a general or limited partnership, the application must be signed by all general partners.
Legal Name  
Trade Name  
Owner/CEO  
 Delivery Address  
City   State   Zip Code  
Telephone   Fax  
 Billing Address  
City   State   Zip Code  
Telephone   Fax  
A/P Contact Person  
email address  
BUSINESS INFORMATION:
Type of Business:
__ Wholesale Distributor __ Retail Distributor __ Grocery Store/Chain
__ Private Institution __ Federal Institiution __ Broker / Service Provider
__ Restaurant __ Fast Foods __ Manufacturer
__ Other (Please Specify):        
           
     
Years in business :
 ____
     
State Tax Exemption No.:
 ___________________________________
     
D-U-N-S No.:
 ___________________________________
BUSINESS OWNERSHIP:
__ Proprietorship __ General Partnership __ Ltd.Partnership
__ Ltd.Liability Co. __ Corporation*    
      
 
*If Incorporated:
*Date Incorporated:
 _______________
     
*State of Incorporation:
 _______________
Complete the following information for individual proprietor of for all partners or corporate officers:
Name   Social Security#   
Title   Drivers License#   State:  
Home Address    Home Phone  
Name   Social Security#  
Title   Drivers License#   State:  
Home Address   Home Phone  
Name   Social Security#  
Title   Drivers License#   State:  
Home Address   Home Phone  

 

 

BANK REFERENCE:
Name    Checking Account No.  
Branch Address   -
Officer's Name   Telephone  
TRADE CREDIT REFERENCES:
Name   Telephone  
Address  

Fax

  
City    State / Zip  
Name   Telephone  
Address   Fax  
City   State / Zip  
Name   Telephone  
Address

 

 Fax  
City   State / Zip -
INDIVIDUAL PERSONAL GUARANTEE:
To induce Diversified Foods, Incorporated (the "Seller") to conduct business with the Purchaser (______________________________________________), the undersigned, jointly and severally, personally and unconditionally guarantee to the Seller the full payment when due of all obligations now or hereafter owing by the Purchaser to the Seller, including, without limitation, all obligations arising out of or in connection with the sale of goods or the provision of services by the Seller and all interest and late charges, attorneys' fees and collection and court costs. This guarantee shall be an unlimited, continuing guarantee and shall remain in full force and effect regardless of any change in the form of evidence of any of the Purchaser's obligations, any renewal, extension or other modification of any security interests. This guarantee may be terminated by an undersigned only as to obligations originating more than five (5) business days after receipt by the Seller of notice of termination given by registered or certified mail. Each of the undersigned hereby waives any rights to notice and waives any right to require the Seller, whether before or in connection with the enforcement of this guarantee, to proceed against any security interest or to pursue any other right or remedy available to the Seller.  The undersigned shall pay all attorneys' fees, court costs and other expenses incurred by the Seller to enforce this guarantee, whether or not incurred in connection with litigation. Each of the undersigned specifically agrees to the venue provisions set forth in the foregoing Credit Application and Agreement. The undersigned also consents to the jurisdiction and venue chosen by the seller.

 

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X
Signature Date Witness Signature Date

 

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Printed Name  Printed Name

 

X

X
Signature Date Witness Signature Date
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Printed Name Printed Name
Print out this form and fill in all required information.
We require the signed original to set up an account.
To start the process ASAP you can fax us a copy of the signed original to (504) 831-8288.