Billing Address

Company Name:  Attention:

Street Address:

City: State: Zip Code:

E-Mail Address:   Telephone:

Office Address

Same as Billing Address (if the same skip this section)

Company Name:  Attention:

Street Address:

City: State: Zip Code:

E-Mail Address:   Telephone:

General Information

Federal Tax ID No.:

Company Composition: Individual Partnership LLC Corporation Sub-Chapter S           Corporation State of:

Dun & Bradstreet No.:

At Present Location Since: Are Premises Leased?: Yes No

Amount of Credit Desired:

Principal / Owner Title:

E-Mail Address:       Phone No. & Extension:

Ordering Information

Are Written Purchase Orders Required? Yes No

Is Merchandise for Resale? Yes No    Resale No.:
                                                                           (If for resale, please fax copy of certificate to (216) 393-9909)

Purchasing Agent

Fax: E-Mail: Phone No. & Extension:

Accounts Payable Contact:

Fax: E-Mail: Phone No. & Extension:

Bank Information

Bank Name: Branch:

Bank Officer Name: Phone No. & Extension:

Steet Address:

City: State: Zip Code:

Type of Account Checking Savings Money Market Line of Credit Other Account No.:

Terms and Conditions

All accounts are COD until a credit application has be completed, reviewed, and approved.  If any indebtedness incurred pursuant to this request for credit is not paid in full when due the undersigned agrees to pay all costs of collection, including reasonable attorneys fee.  Any balance so remaining unpaid shall bear interest at the lesser rate of 1.5% per month or the maximium rate permitted by applicable law, until paid in full.

Enter your initials if you have read, understood, and accepted the terms and conditions:

Acceptance and Approval

Signing this agreement indicates your acceptance of the terms and conditions as stated.  In addition you authorize Ohio Energy Source, Inc. to make any and all inquiries necessary to process this credit application.

Name of Authorized Representative: Title:

Phone No. & Extension:   Date:

Enter your e-mail address as your signature

Click here to submit your credit application