Billing Application

Corporate or Official Name *

D.B.A.

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is physical address the same as mailing? *

Yes
No

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Billing Email Address *

We only offer email as a billing option.

Type of Business *

Corporation
Proprietorship
Partnership
LLC

Federal ID Number *

Tax Exempt? *

Yes
No

Tax Exempt Form *

Click or drag a file to this area to upload.

We have a button to download the Ohio Tax Exempt form at the bottom of this screen.

Partners, Owners, or Officers Name(s) *

Please include a direct phone number and/or email addresses

Date Business Began *

Has this business declared bankruptcy? *

Yes
No

If yes, please explain *

Has any company which you owned ever declared bankruptcy? *

Yes
No

If yes, please explain *

Do you have any pending lawsuits against you? *

Yes
No

If yes, please explain *

In order to expedite service, we ship all parts directly to our customers. Would you like us to ship the parts to the service address or to another location? *

Ship to the service address
Ship to an alternate location

Alternate Location *

Sometimes apartment complexes prefer all parts to be shipped to the main office. We also see companies accepting deliveries at Shipping & Receiving or an Maintenance Office.

Would you like us to reach out to you to provide a quote for all repairs that will cost more than the service charge, or would you like to give us an amount that you would like to pre-authorize? *

Reach out to me to provide a quote for all repairs that will cost more than the service charge
We authorize you to repair a unit as long as the total repair cost is under the specified amount below (including service charge)

Pre-Authorized Amount *

Commonly, businesses choose $300 as a pre authorized amount. Any time we exceed that amount on a repair, we will reach out to you to see if you would like to move forward with the repair.

How would you prefer us to contact you to quote a repair? *

Phone
Email
On-Site Staff Member

Who do we reach out to for the purpose of providing a quote? *

First

Last

Who do we reach out to when the repair exceeds your pre-authorized amount? *

First

Last

Who is the on-site staff member that we can reach out to? *

First

Last

What is a good contact number the technician can use to reach the on-site staff member at the time of service? *

Where can we email the quote to? *

What phone number would you like us to call to provide the quote for the repair? *

Credit Reference #1

Business Name *

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Credit Reference #2

Business Name *

Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

How many appliances do you expect to schedule for service with Fred's Appliance each year? *

Terms of Service *

I agree to the Terms

ALL APPLICATIONS APPROVED FOR CREDIT ARE GOVERNED BY THE FOLLOWING CONDITIONS: PAYMENTS ARE EXPECTED TO BE MADE IN ACCORDANCE WITH THE TERMS SO STATED ON EACH INVOICE; HOWEVER, NO SHIPMENTS THAT CAUSE THE ACCOUNT TO EXCEED ITS LINE OF CREDIT SHALL BE MADE UNLESS APPROVED BY THE CREDIT DEPARTMENT. FURTHERMORE, NO ACCOUNT HAVING A PAST DUE BALANCE SHALL BE SHIPPED UNLESS ARRANGEMENTS ARE MADE WITH THE CREDIT DEPARTMENT ADVANCE NOTICE IN WRITING MUST BE MAILED TO THE CREDIT DEPARTMENT OF FRED'S APPLIANCE LLC OF ANY CHANGE IN THE BUSINESS STRUCTURE, SUCH AS INCORPORATION, CHANGE OF OWNERSHIP, ETC. WITHOUT SUCH NOTICE, THE ORIGINAL PRINCIPALS TO WHOM CREDIT WAS EXTENDED SHALL REMAIN LIABLE CREDIT LIMITS CAN BE REVISED UPON REVIEW BY FRED'S APPLIANCE LLC APPLICANT IS NOT PRESENTLY THE SUBJECT OF ANY PROCEEDINGS UNDER THE FEDERAL BANKRUPTCY CODE. TITLE 11 U.S.C INCLUDING ANY CHAPTER 11 PLAN WHICH HAS NOT BEEN COMPLETELY CONSUMMATED, NOR IS IT THE SUBJECT OF ANY RECEIVERSHIP, TRUSTEESHIP, OR INSOLVENCY PROCEEDING UNDER STATE LAW. APPLICANT SHALL PROMPTLY NOTIFY FRED'S APPLIANCE LLC IF IT BECOMES THE SUBJECT OF ANY FEDERAL OR STATE INSOLVENCY PROCEEDINGS, RECEIVERSHIP, OR TRUSTEESHIP. THIS CREDIT AGREEMENT SHALL BECOME VALID WHEN ACCEPTED BY FRED'S APPLIANCE LLC AND SHALL BE DEEMED MADE AND ENTERED INTO LAKE COUNTY, OHIO. THE UNDERSIGNED AND FRED'S APPLIANCE LLC ACKNOWLEDGE AND AGREE THAT ANY FAILURE TO PAY FOR GOODS SOLD TO THE UNDERSIGNED ON CREDIT, FOR WHICH PAYMENT IS NOT RECEIVED IN A TIMELY MATTER, SHALL BE DEEMED TO BE ACTIVITY GIVING RISE TO A CLAIM IN LAKE COUNTY, OHIO, SUCH CLAIM FOR RELIEF ARISING IN LAKE COUNTY, OHIO, AND VENUE OF ANY CASE OR CONTROVERSY ARISING OUT OF SUCH NONPAYMENT SHALL BE PROPER IN LAKE COUNTY, OHIO REGARDLESS OF ANY OTHER COUNTY OR STATE IN WHICH VENUE WOULD BE PROPER. IF IT BECOMES NECESSARY FOR FRED'S APPLIANCE LLC TO INCUR COLLECTION COSTS FOR ANY CREDIT EXTENDED UNDER THIS APPLICATION, THE UNDERSIGNED HEREWITH PROMISES TO PAY ADDITIONAL COLLECTION COSTS INCLUDING REASONABLE ATTORNEY FEES. THE INFORMATION CONTAINED ON THE CREDIT APPLICATION IS TRUE TO THE BEST OF THE KNOWLEDGE OF THE UNDERSIGNED.

Today's Date *