Automatic Payment Account Application

Automatic Payment Account Application via Credit Card

Simply fill out the form below to apply for an Automatic Payment Account that allows you to conveniently pay by credit card. One of our account representatives will contact you immediately to confirm your account information.

Automatic Payment Account Application

Please ignore sign in requirement, it is a bug in Google Forms. You can fill this out without having to sign in to Google.

Name of person opening the account:

Contact phone number of person opening the account

Firm's Legal Name

d/b/a if applicable

Do you require references for you orders and invoicing needs?
To help sort your bill you can have references attached to each order and then have the invoice subtotaled accordingly.

Yes No

Street Address

Room#

City

State

Zip Code

Main business phone number if different than above

Person in charge of processing bills

Persons Title

Persons Email

This is the Agreement that establishes your Client account with us and the terms and conditions of your account.

By requesting and permitting us to provide delivery services to you the Client, Client confirms acceptance of the terms and conditions of this Agreement. Client is responsible for all amounts owed on this account, whether charged by the Client, a person whom you permit to use your account to order services from us, or any other person using your account with actual, implied or apparent authority.

PAYMENT TERMS:

Unless other terms are arranged, payment is due within 15 days of the billing date. If this account becomes overdue, MON NIC BB reserves the right to suspend service, without notice, until overdue balances are paid. Should this account be placed with a collection agency and/or law firm, fees will be added to the balance due.

INSURANCE:

All deliveries are insured for $100.00. If you would like to declare a greater value on a shipment, the value must be declared and insurance must be purchased prior to the time of shipment.

Printed Name

Title

Today's Date