Fill out the form below and submit or download the PDF to fax, mail, email, or bring into the store.
City / State
Married or Single?
Drivers License Number
Bank Name & Address
How long have your worked here?
Landlord (if applicable)
Landlord's Phone Number
Receive invoices by email?
Name of nearest relative not living with you
Relative's Phone Number
Personal Guaranteed Payment of charges incurred by the applicant:
I agree to payment of monthly account due by the 5th of the month following the month of purchase. I agree to pay a late fee of 1.5% per month until paid in full, if not paid by the 10th. I agree to pay reasonable attorney fees and all collection expense if not paid by these terms. All accounts will be put on credit hold after 60 days and after 90 days a lien will be filed on the property where the material was delivered. Any payment on account by credit card is subject to a 3% convenience fee.
I agree to all terms above.