Koolhaas Nursery No. 1, Inc.
30610 CR 437 Plymouth Sorrento Rd / PO Box 1026
Sorrento FL 32776
Phone: 352.383.9143 email:ckoolhaas@earthlink.net

www.koolhaasnursery.com

Credit Application

Full Name of company: _______________________________________
 Business type (check one):
___ Individual ___Corporation ___ Partnership

Physical Address:____________________________________________ 

City:________________ State: ____ Zip: ___________

Business premises (check one):
 __ Owned  ___ Leased  ___Rented

Phone: ______________________ Fax:______________________ 

Email: _________________________________________________ 

Mailing address: ________________________________________ 

City: _________________ State: ____________ Zip: __________

Date Established: ______________ Number of Employees: ______________

Annual Sales: $________________

Federal Tax ID# (EIN or owner's social security number): ______________________

Owner/Officer's name: __________________________Title: ___________________

Home Address: _______________________________________________________

City:________________ State: ____ Zip: ___________

Home Phone: _________________________ Drivers License #: ________________

Trade References

Company Name: _____________________

Contact:__________________________

Phone:_______________________

Company Name: ___________________________

Contact: __________________________________

Phone: ___________________________________

Company Name: ___________________________

Contact: __________________________________

Phone: ___________________________________

Terms: Open accounts are net 30 days. Delinquent accounts (beyond 30 days) are subject to 1½% interest per month (18% per year). Customer assumes responsibility for all collection costs and reasonable attorney's fees, the venue for any litigation will be Lake County, Florida.

Returned check fee $20.00

Bank Reference

Bank Name: __________________________________________ Contact: _______________________

Address: ______________________________________________ Phone: _______________________

Account Number: _____________________________________________________________________

I hereby agree to the above terms and authorize the above named bank to release information to Koolhaas Nursery No. 1, Inc. for the purpose of evaluating credit worthiness.
Owner/Officer Signature: ______________________________________ Date: ______________________