Dandy Works Credit Check WebsiteFirst NameLast NameEmailGoDandyCOMPANY INFORMATION Company Name State of Incorporation —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Company Address City State ZIP Code Company Phone Type of Business —Please choose an option—Sole ProprietorshipPartnershipLimited Liability CompanyC-CorpS-Corp Tax Exempt? —Please choose an option—NoYes Federal Tax ID Date Established Annual Sales Net Worth Credit Line PRINCIPAL OWNERS/OFFICERS OWNER/OFFICER 1 Name Title Address City State ZIP Code Social Security Number OWNER/OFFICER 2 Name Title Address City State ZIP Code Social Security Number AGREEMENT I (We) understand and agree that the information furnished for you on this page is for the purpose of obtaining credit from your firm. I am (We are) authorized, in my (our) capacity, to bind my (our) company accordingly. I (We) hereby agree that all accounts or monies due DANDY MINI MARTS, INC. shall be due and payable at 6221 Mile Lane Road, Sayre, Pennsylvania 18840, that all past due accounts, notes, or judgments shall automatically draw interest at the maximum rate allowable by law, that I (We) agree to pay all costs of collection, including but not limited to collection fees, court costs, financial charges, and attorney fees, that all contracts are performed in Sayre, Bradford County, Pennsylvania. Further my (our) electronic signature(s) indicates that I (we) understand and hereby accept said agreement. Authorized Signature 1 Title Authorized Signature 2 (if applicable) Title PERSONAL GUARANTY I hereby state that the above information is true and correct, and that Dandy Mini Marts, Inc. has the right to investigate this information to the extent it deems necessary to check the credit history of the above business and of my own personal credit history. In consideration for credit sales made by Dandy Mini Marts, Inc. to me or the above business, I personally guarantee all indebtedness therein created. The guaranty is an absolute, complete and continuing guaranty. If the above Business can limit the payment of its obligations to Dandy Mini Marts, Inc. for such indebtedness. I agree that Dandy Mini Marts, Inc. does not have to give me notice of indebtedness or any extension of credit already in existence or hereafter contracted by the above business. The terms of credit sales offered by Dandy Mini Marts, Inc. may be rearranged, extended and/or renewed without notice to me. I agree to pay all costs of collection including but not limited to, collection fees, court costs, finance charges (at a rate limited only by law), judgments and attorney fees. I agree that judgments may draw interest at a rate limited only by law. I understand that payment is to be made to Dandy Mini Marts, Inc., at 6221 Mile Lane Road, Sayre, Pennsylvania 18840. Name Title Driver's License Number Driver's License State —Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Date of Birth Social Security Number Mailing Address City State ZIP Code Email Signature
