Company Name:            

 FEIN#:

Individual Name:

Soc. Sec. #:

Street Address:

P.O. Box:

City:

State: AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MS MO MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SD SC TN TX UT VA VT WA WI WV WY         Country:

Phone Number:  

Fax Number:

Email Address:

Type of Business:

Years in Business:       

 Amount of Credit Requested:

Please choose on of the following:

Sole Proprietor    Partnership    Corporation

Names of Principals in Partnership or Corporation

Credit References (Full Name, Address, Phone Number)

Bank Name:   Phone #:
Bank Address:

Trade:

Name:   Phone #:
Address:

Name:   Phone #:
Address:

Name:   Phone #:
Address:

TERMS: Submission of this form shall be treated as an original signature.  INVOICES ARE DUE AS DIRECTED.  ANY PAYMENT NOT MADE WHEN DUE SHALL ACCRUE INTEREST A THE RATE OF 18% PER ANNUM, COMPOUNDED MONTHLY.  ALL COST OF COLLECTION, INCLUDING REASONABLE ATTORNEY FEES, SHALL BE PAID BY APPLICANT. Applicant agrees that, if credit is extended to Applicant at any time by American Midwest Equipment Company, all sales of service or goods made by American Midwest Equipment Company or rental of equipment by American Midwest Equipment Company to applicant shall be governed by and construed according to the internal laws of the state of Wisconsin.  Applicant further agrees that all claims or disputes between American Midwest Equipment Company and Applicant relating to the purchase of any goods or services or the rental of any equipment shall be brought in Waukesha County, Wisconsin and that the State of Wisconsin Courts are Courts of competent jurisdiction.  APPLICANT HEREBY AUTHORIZED THE RELEASE OF ANY FINANCIAL INFORMATION ABOUT APPLICANT, IT'S PRINCIPALS AND OFFICERS.