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Firm Name(*)

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Phone (XXX-XXX-XXXX)(*)

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Email(*)

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Fax

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Service Address

Service Address(*)

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City/State(*)

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Zip(*)

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Billing Address if different that Service Address

Billing Address

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City/State

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Zip

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Company Information

Years Established(*)

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Your Company is(*)

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Federal ID or SS#(*)

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Have you ever filed bankruptcy?(*)

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Name & Branch of Bank(*)

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Checking Account #(*)

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Savings Account #

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Do you own the business property?(*)

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If a corporation, do stockholders own property?

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Current Credit References - Please List 3

Name(*)

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Address(*)

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City/State/Zip(*)

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Phone (XXX-XXX-XXXX)(*)

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Name(*)

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Address(*)

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City/State/Zip(*)

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Phone (XXX-XXX-XXXX)(*)

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Name(*)

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Address(*)

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City/State/Zip(*)

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Phone (XXX-XXX-XXXX)(*)

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We have available credit card or bank card Auto Pay that is processed on the 5th of each month, if you are interested check below.

Auto Payment (*)

Yes, I would like to signup for Auto Pay
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Terms of Service

TERMS: NET 30 DAYS. ACCOUNTS NOT PAID BY THE LAST BUSINESS DAY OF THE MONTH FOLLOWING STATEMENT DATE ARE DELINQUENT AND SUBJECT TO A LATE CHARGE OF 1.5% OF THE DELINQUENT AMOUNT PER STATEMENT PERIOD. THE CUSTOMER IS RESPONSIBLE FOR ANY DAMAGE TO AMERICAN REFUSE’S PROPERTY. THE CUSTOMER IS ALSO RESPONSIBLE FOR THE CONTENTS OF THE CONTAINER. AMERICAN REFUSE IS AUTHORIZED TO CONTACT ANY REFERENCES LISTED ABOVE. ALL STORAGE CONTAINER ACCTS 60 DAYS PAST DUE, THE CONTENTS WILL BE LIQUIDATED & ALL COST INCURRED WILL BE PAID BY THE CUSTOMER.

CERTIFICATION:CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT. I HAVE READ AND UNDERSTAND THE TERMS AND RATES AS STATED AND AGREE TO PAY THE ACCOUNT IN THE ABOVE NAME WITHIN THESE TERMS. IN THE EVENT I FAIL TO PAY, AND IT BECOMES NECESSARY TO PLACE THIS ACCOUNT IN THE HANDS OF AN ATTORNEY FOR COLLECTION, I AGREE TO PAY A REASONABLE ATTORNEY FEE FOR ITS COLLECTION.

Terms Agreement(*)

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GUARANTEE:I HEREBY GUARANTEE TO AMERICAN REFUSE THE PAYMENT OF ANY AND ALL DEBTS OF THE ABOVE COMPANY. THIS IS A CONTINUING GUARANTEE AND SHALL REMAIN IN FORCE UNTIL REVOKED BY THE GUARANTOR GIVING WRITTEN NOTICE TO AMERICAN REFUSE.

Guarantor Full Name(*)

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Request for Service - Commercial

Office Info

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