T. H. Brooks & Associates
4415 Parkbreeze Court     Orlando, Florida  32808
Ph: (407) 298-2777            Fax (407) 298-3242
Print application and complete information.  After signing, fax to
(407) 298-3242 and mail original to the address listed above.
General Information
Company Name:
DBA (if different):
Contact Person:
Billing Address:
City:			State:			Zip + 4:
Phone:			Fax:			E-Mail:
Shipping Address:
City:			State:			Zip + 4:
Company Profile
Federal Tax ID or SSN:
Type of Business:				No. of Employees:
Date Business Established:
Amount of Credit Requested:
Tax Exempt (please circle one):				Yes		No
Tax Exempt Number (please attach copy of certificate):
Please circle one:		Corporation		Partnership		Sole Proprietorship
If Corporation:		Date Incorporated:			State of Incorporation:
Names and Titles of Three Chief Coporate Officers or Partners:
	1.
	2.
	3.
Purchase Order Required (please circle one):					Yes		No
Bank References
Name of Bank:
Address of Bank:
City:			State:			Zip + 4:
Phone:				Contact Person:
Account #:
Name on Account:
Trade References
Reference #1		Name:
		Address:
		City:		State:		Zip + 4:
		Phone:			Fax:
Reference #2		Name:
		Address:
		City:		State:		Zip + 4:
		Phone:			Fax:
Reference #3		Name:
		Address:
		City:		State:		Zip + 4:
		Phone:			Fax:
Terms and Conditions of Sale
I/we, the undersigned, hereby apply to T.H. Brooks & Associates, Inc. (hereinafter referred to as Seller) for an
account and as a basis for granting same, I/we submitted the above information which, to the best of my/our
knowledge and belief, is true and correct.  If an account is opened by the Seller, I/we agree:
To pay seller on or before the due date indicated on each invoice.  I/we understand that statements will be
received by me/us for the purpose of reconciling my/our accounts payable balance due to Seller
To pay a service charge of 1-1/2% monthly (18% annually) on any invoice paid after the due date indicated
on each invoice.  Also, I/we understand that the account will be subject to suspension of credit privileges
should delinquency occur.
That in the event of default in the payment required to be paid hereunder, Seller may forthwith declare the
balance immediately due and payable.  If upon default as aforesaid, and Seller places account for
collection, I/we agree to pay all cost incurred by Seller, including reasonable attorney fees.
That venue of any action to enforce any provisions of this agreement shall be Orange County, State of Florida.
That all materials ordered, delivered, and/or fabricated are subject to Seller's terms and conditions of sale.
Any modification and/or alteration of purchase order, purchase agreement or contract must be in writing
acknowledged by Seller.  This provision takes precedence over all subsequent action, written, oral,
direct or implied, subject to compliance with the above stated requirements.
In the event that the buyer is a corporation, then the officers who are signing this agreement on behalf of the
corporation pledge their person guarantee and agree to be personally liable for any indebtedness incurred by
the corporation jointly and severally with the corporation.
The undersigned hereby authorizes any bank or other grantor of credit to provide financial information to T. H.
Brooks & Associates, Inc. as requested for the purpose of establishing an account.
Authorized Signatures
Authorized Signature:
Printed Name:
Title:						Date:
Authorized Signature:
Printed Name:
Title:						Date: