Central Concrete Supply Co Inc. - Credit Application

For your convenience we have added a credit application to our site. All fields with red asterisk (*) are required to be filled in, so we can process your application in a timely matter. Gramm-Leach-Biley Act Notification

Original must be printed, signed and mailed to:
755 Stockton Ave, San Jose, CA 95126
for account to be activated. Thank you.

CREDIT APPLICATION & AGREEMENT

APPLICATION MUST BE FILLED OUT COMPLETELY. TO AVOID DELAY IN PROCESSING YOUR ORDERS, PLEASE RETURN TO OUR CREDIT MANAGER IMMEDIATELY. PLEASE TYPE OR PRINT CLEARLY.

NOTE: YOU MUST FILL OUT THE FIELDS WITH ( * ) Download a Printable Version PDF file

*NAME:

*EMAIL

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

PHONE&FAX eg: 408-8951276

*BUSINESS LIC:

* PHONE:

FAX:

*DRIVERS LIC:

*CONTRACTORS LIC:

eg: MM/DD/YYYY

*EXPIRATION DATE:

*COUNTY:

CHECK ONE

CONTRACTOR

PARTNERSHIP

CORPORATION

SOLE OWNER

*YEAR STARTED:

CHARGE SALES TAX?

YES

IF NO RESALE NUMBER:

HAS COMPANY OR ANY OF THE PRINCIPALS FILED BANKRUPTCY?

YES

IF YES WHAT CHAPTER?

NAME OF DEBTOR:

INCORPORATED OR PARTNERSHIP (LIST OFFICERS OR PARTNERS)

PRESIDENT OR SOLE OWNERSHIP

*NAME:

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

SSN eg: 999999999

*SOCIAL SEC. NO:

*DRIVERS LIC. NO:

*TELEPHONE NO:

VICE PRESIDENT

*NAME:

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

*SOCIAL SEC. NO:

*DRIVERS LIC. NO:

*TELEPHONE NO:

SEC./TREAS.

*NAME:

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

*SOCIAL SEC. NO:

*DRIVERS LIC. NO:

*TELEPHONE NO:

BANK REFERENCE

*BRANCH:

*ACCOUNT NO:

*D&B NO.

GIVE THREE CREDIT REFERENCES:

REFERENCE 1:

*NAME:

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

*TELEPHONE NO:

FAX NO:

REFERENCE 2:

*NAME:

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

*TELEPHONE NO:

FAX NO:

REFERENCE 3:

*NAME:

*ADDRESS:

APT/SUITE#:

*CITY:

*ZIP:

*TELEPHONE NO:

FAX NO:

TERMS:
CONCRETE - $1.00 PER YARD- 10TH PROX. NET 30 DAYS

CLICK HERE FOR ADDITIONAL TERMS AND CONDITIONS

I have read, understand and accept the above terms and condition of sale. I have provided true and correct information to the best of my knowledge. I further authorize Central Concrete Inc. to verify any and all references given, to include but not limited to, trade and bank references and commercial/consumer credit reporting agencies that Central Concrete Inc. considers necessary to determine our credit capabilities. I promise full and prompt payment of all indebtedness, obligations and liabilities of every kind, present and future, incurred by the applicant for product and or services purchased from Central Concrete Inc. I agree to pay all cost of collections including reasonable attorneys' fees and all court costs. I here by waive notice of acceptance, default and exemption. Jurisdiction and venue for any dispute shall be in the courts of California. If any term or provision of this application, including, but not limited to, the above "Terms and Conditions" or "Personal Guarantee" is determined to be invalid or unenforceable under present or future laws, such provision shall be severable, and shall not invalidate the remainder of the terms on this application.