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City:  *
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Business Phone:  *
Business Email:  *
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Reason for this form:

It is expressly understood and agreed that by filling out this form the information is being furnished in order to induce Optical Wholesale to extend credit, accommodations and other benefits. The person filling out this form is authorizes Optical Wholesale, any credit bureau or other investigative agency employed by Optical Wholesale ti investigate references, statements, or other persons pertaining to my credit and financial responsibility. In the event applicant\'s account is placed in the hands of an attorney for collection, I agree and warrants, agree and promises any attorney\'s fee or fifteen percent (15%) of the outstanding balance then due and owing at the time this applicant\'s account is received by the attorney for legal action.

Optical Wholesale renders billings immediately upon shipment. If your account is paid on or before the 10th day of the month following the purchases of merchandise and invoice date, you will be allowed a twenty (20%) discount on all prescription work. All invoices rendered are due in full by the last day of the month following the month in which merchandise is purchased and invoices are rendered otherwise, A late or finance charge will be assessed in the amount of fifteen percent (15%) per month (eighteen percent 18% per annum) on all past due balances of principle.

I understand and agree to everything in this form, I further state I am authorized by this organization to make this agreement. I understand I may be asked to fill out and sign a hard copy (paper) of this agreement and I agree to do so.