--- type: document title: Credit-Application-for-Tipping-Fee-at-Transfer-Station-.65ae311 file: ../Credit-Application-for-Tipping-Fee-at-Transfer-Station-.65ae311.pdf tags: - Russell_County - Solid_Waste_Department docDate: null contentType: application/pdf contentLength: 271988 sha256sum: f2c4ce629aa4625e5a257a5f05d5f4734c47de48c2f0cfebe40be95e6371866c sha1sum: 71b63cf654a5c4757e02d3b17a6232efebb7b1fd --- RUSSELL COUNTY SOLID WASTE DEPARTMENT 137 HIGHLAND DR PO BOX 1208 LEBANON, VA 24266 TEL: (276) 794-7826 FAX (276) 889-8011 APPLICATION FOR COMMERCIAL/BUSINESS CREDIT ACCOUNTS Please type or print clearly LEGAL COMPANY NAME ___________________________________________________________ Physical Address: __________________________________________________________________ Mailing Address: __________________________________________________________________ Phone(s): ________________________ Fax: ________________________ Accounts Payable Contact: _____________________________ Phone: _____________________ E-mail address: ____________________________________________________________________ Other Trade Name(s): _______________________________________________________________ Tax ID #: _________________________ Year Established: ________________ PRINCIPAL OFFICERS/OWNERS 1. Name: ______________________________________ Title: ________________________ Resident address: __________________________________________________________ Phone: ______________________ 2. Name: ______________________________________ Title: ________________________ Resident address: __________________________________________________________ Phone: ______________________ 3. Name: ______________________________________ Title: ________________________ Resident address: __________________________________________________________ Phone: ______________________ RUSSELL COUNTY SOLID WASTE DEPARTMENT 137 HIGHLAND DR. PO BOX 1208 LEBANON, VA 24266 TEL: (276) 794-7826 FAX (276) 889-8011 APPLICATION FOR COMMERCIAL/BUSINESS CREDIT ACCOUNTS Please type or print clearly LEGAL COMPANY NAME Physical Address: Mailing Address: Phone(s): Fax: Accounts Payable Contact: Phone: E-mail address: Other Trade Name(s): Tax ID #: Year Established: PRINCIPAL OFFICERS/OWNERS 1. Name: Title: Resident address: Phone: 2. Name: Title: Resident address: Phone: 3. Name: Title: Resident address: Phone: BANK REFERENCE 1. Bank Name: _____________________________ Business Checking Account No. _______________ Branch Phone No. _______________________ CREDIT REFERENCES 1. Name: _______________________________________ Account #: ___________________________ Address: _________________________________________ Phone/Fax: _______________________ City/State/Zip: _____________________________________ Contact: _________________________ 2. Name: _______________________________________ Account #: ___________________________ Address: _________________________________________ Phone/Fax: _______________________ City/State/Zip: _____________________________________ Contact: _________________________ 3. Name: _______________________________________ Account #: ___________________________ Address: _________________________________________ Phone/Fax: _______________________ City/State/Zip: _____________________________________ Contact: _________________________ All statements made herein are true and correct to the best of my knowledge. We authorize Russell County to make any and all inquiries necessary for evaluation of this applicated we indemnify Russell County and its agents from any and all liability resulting from their survey. Further, we hereby authorize the bank and trade references listed in this credit application to release information necessary to assist Russell County in establishing an account for us. I hereby apply to Russell County Solid Waste Department for establishment of a charge account at the Russell County Solid Waste Transfer Station and certify that I am empowered by the applicant to sign and incur debt, and agree to pay Russell County when invoices are submitted. PAYMENT TERMS: Net 30 ______________________________________ _____________________________________ Printed Name Title ______________________________________ _____________________________________ Signature Date BANK REFERENCE 1. Bank Nam Business Checking Account No. Branch Phone No. CREDIT REFERENCES 1. Name: ‘Account #t Address: Phone/Fax: City/State/Zip: Contact: 2. Name: Account #: Address: Phone/Fax: City/State/Zip: Contact: 3. Name: ‘Account #: Address: Phone/Fax: City/State/Zip: Contact: All statements made herein are true and correct to the best of my knowledge. We authorize Russell County to make any and all inquiries necessary for evaluation of this applicated we indemnify Russell County and its agents from any and all liability resulting from their survey. Further, we hereby authorize the bank and trade references listed in this credit application to release information necessary to assist Russell County in establishing an account for us. hereby apply to Russell County Solid Waste Department for establishment of a charge account at the Russell County Solid Waste Transfer Station and certify that | am empowered by the applicant to sign and incur debt, and agree to pay Russell County when invoices are submitted. PAYMENT TERMS: Net 30 Printed Name Title Signature Date ACCOUNT TERMS AND AGREEMENT The undersigned hereby makes application for credit from RUSSELL COUNTY. The undersigned agrees to the following terms of payment: 1. The monthly statements shall be due and payable within 30 days from the Billing Date. 2. The undersigned agrees to cost of collection including a reasonable attorney’s fee, and interest accruing at the rate of (18%) per annum on all amounts past due. 3. This document shall be considered to have been executed in Russell County, Virginia and the undersigned shall agree that it be governed and construed in accordance with the laws of the Commonwealth of Virginia. 4. The undersigned agrees that written notice shall be given to Russell County of any billing ticket or statement errors within fifteen (15) days of the date thereon. 5. The fact that this application contains a request for an estimate of monthly credit required shall not be deemed a limitation of liability by the undersigned or any guarantor. 6. The undersigned acknowledges and agrees that credit checks may not be limited to the references listed on this application. 7. If the applicant is a corporation, the person signing the application on behalf of the applicant warrants that he/she is authorized to do so. If the applicant is not a corporation at the time of the application, and subsequently incorporates his/her business, with or without the knowledge of Russell County, the applicant agrees to be jointly and severally liable to Russell County for any indebtedness incurred by or transferred to such corporation. 8. The undersigned agrees to provide Russell County with prior written notice of any change in the business structure (e.g. incorporation, change of ownership, etc.). Any such notice shall be mailed by certified or registered mail, return receipt requested, and shall be effective after the expiration of five (5) days after the date such notice is received by Russell County. Without such notice, the original principals to whom credit was extended shall remain liable under the terms of this credit application. Signature ___________________________________________ Date ________________ Authorized Agent Title Signature ___________________________________________ Date ________________ Authorized Agent Title ACCOUNT TERMS AND AGREEMENT The undersigned hereby makes application for credit from RUSSELL COUNTY. The undersigned agrees to the following terms of payment: 1. The monthly statements shall be due and payable within 30 days from the Billing Date. 2. The undersigned agrees to cost of collection including a reasonable attorney’s fee, and interest accruing at the rate of (18%) per annum on all amounts past due. 3. This document shall be considered to have been executed in Russell County, Virginia and the undersigned shall agree that it be governed and construed in accordance with the laws of the Commonwealth of Virginia. 4. The undersigned agrees that written notice shall be given to Russell County of any billing ticket or statement errors within fifteen (15) days of the date thereon. 5. The fact that this application contains a request for an estimate of monthly credit required shall not be deemed a limitation of liability by the undersigned or any guarantor. 6. The undersigned acknowledges and agrees that credit checks may not be limited to the references listed on this application. 7. \f the applicant is a corporation, the person signing the application on behalf of the applicant warrants that he/she is authorized to do so. If the applicant is not a corporation at the time of the application, and subsequently incorporates his/her business, with or without the knowledge of Russell County, the applicant agrees to be jointly and severally liable to Russell County for any indebtedness incurred by or transferred to such corporation. 8. The undersigned agrees to provide Russell County with prior written notice of any change in the business structure (e.g. incorporation, change of ownership, etc.). Any such notice shall be mailed by certified or registered mail, return receipt requested, and shall be effective after the expiration of five (5) days after the date such notice is received by Russell County. Without such notice, the original principals to whom credit was extended shall remain liable under the terms of this credit application. Signature Date ‘authorized Agent Title Signature Date “authorized Agent Tie