Credit ApplicationBack

The Burton Corporation and Its wholly-owned brands

* Required Fields

Brands Requested  *

Legal Business Information

Headquarters  * Primary Retail Location
Copy from Headquarters

Primary Shipping Location  *

Primary Contact People

  Name E-Mail

Additional Locations

List locations in addition to primary retail and shipping locations.

Credit Information

Credit Terms Requested:

 

Proprietor(s), Partner(s), or Principal(s):  *

Names:
Social Security/Social Insurance Numbers:
Home Address:
Home Phone:

Who do we contact on credit matters?

Name:
E-Mail:
E-Mail for e-invoicing/statement:
Contact Phone:
How Long in Business:
Has there been a change in ownership in the last three years? Yes No
State/Province incorporated in:
Federal Tax ID #:
State Tax Vendor ID #:
Provincial Sales Tax ID #:
Value of building if owned:
If rented, annual rent:
Bank:
Acct #:
Bank Contact:
Phone:
GST/HST/PST #(Canada Only):
QST #(Canada Only):
Bankruptcy or compromised debt in last 7 years? Yes No
Are you in collection with an attorney or collection agency? Yes No
Any judgments been issued against you? Yes No
Do you finance your inventory on a secured basis? Yes No From Whom?
Are any assets pledged or debts secured (UCC or PMSI)? Yes No To Whom?

 

YOUR MOST RECENT FINANCIAL STATEMENT (BALANCE SHEET, PROFIT, AND LOSS STATEMENT) MUST BE AVAILABLE FOR REVIEW

Insurance information

Insurance carried (specify):
Ever have a fire loss (if yes, provide details): Yes No Details
Name of products liability insurer and parent co. policy limit :

Other Brands

Check all brands you sell in your stores:

Other major brands:

 

Signature

TINY TYPE OUR LEGAL DEPARTMENT IS MAKING US INCLUDE:

For the purpose of obtaining merchandise from The Burton Corporation and its wholly-owned brands (collectively, "Burton") on credit, Dealer provides the above information (including the attached balance sheet and profit and loss statement) and represents and warrants to Burton that the information is complete, true, and accurately reflects the present financial condition of Dealer. Burton has the right to rely on and verify the information you provide. Dealer understands a credit report may be obtained in order to process this Credit Application.

Owner or Authorized Officer's Signature *

Date *