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Full Name
Title
Email
Website
Business Name
Business Type
Date Established
Owner Full Name
Business Address
Business City
Business State
Business Zip
Phone Number
Fax Number
Tax ID Number
JBT Number
Bank Name
Bank Number
Bank Contact Name
Vendor Name #1
Vendor #1 Phone
Vendor #1 Fax
Vendor #1 Contact Name
Vendor Name #2
Vendor #2 Phone
Vendor #2 Fax
Vendor #2 Contact Name
Vendor Name #3
Vendor #3 Phone
Vendor #3 Fax
Vendor #3 Contact Name
Vendor Name #4
Vendor #4 Phone
Vendor #4 Fax
Vendor #4 Contact Name
Comments

It is understood and agreed that payments received beyond the terms stated on Yerudiam invoices will be
subject to late charges. As a further inducement to extend credit, I agree that in the event a lawsuit is
brought on with regards to any obligation hereafter owed by me to Yerudiam, that I will (1) pay for
reasonable attorney’s fees and necessary collection costs incurred by Yerudiam in collecting the said
obligation; and (2) pay collection agency costs or collection costs even if the lawsuit is not instituted.


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