Open an account online at www.petra.com/application Fast Fax Order/Credit Card Authorization For more terms please see the complete credit application or view Petra Industries, LLC's ("Petra") standard terms at www.petra.com/terms. Company Name/Account No.: Customer P.O. No.: Fed I.D. No.: State Tax Resale No.: SHIP TO: Business Residence City: State: Zip: Phone No.: ( ) Fax No.: ( ) Billing Address: City: State: Zip: Phone No.: ( ) Fax No.: ( ) Credit Department: 866-604-7287 Credit Fax: 866-604-7288 Primary Contact Email Address: Email Address for Invoices: Email Address for Statements: ORDER FORM SHIP VIA: FREIGHT FOB: QTY PART # DESCRIPTION PRICE PER AMOUNT 1 2 3 4 ORDERED BY: TOTAL COMMENTS/SPECIAL INSTRUCTIONS: CREDIT CARD INFORMATION Please complete this section Card is a: Credit Card Debit Card* if paying by credit/debit card: Credit Card Number Expires Please print name EXACTLY as it appears on card____________________________________________________________________ Authorized users____________________________________________________________________________________________ Billing Address of Card Holder__________________________________________________________________________________ City_ ________________________________________________________________ State_ _________________ Zip Customer represents that it is the cardholder, is authorized to use the credit card(s) and authorizes Petra to process all payments on this credit card(s) regardless of the ship-to address. It is not necessary that the ship-to address and Customer billing address are identical. Any and all charges for product ordered on Customer’s account, regardless of shipping destination, are the responsibility of Customer and will be charged to the credit card(s) authorized herein. Customer understands that by utilizing a debit card for payment, the issuing financial institution may subject Customer’s account to an authorization hold. An authorization hold is a common banking industry practice by which Customer's financial institution places a hold on any available balance equal to Customer's purchase amount while Petra processes payment. The exact dollar amount and the timeframe for a release of any authorization hold are set by Customer’s financial institution. Petra shall not be responsible for any fees or charges incurred as a result of Customer’s use of a debit card, including, but not limited to any fees or charges incurred by Customer as a result of an authorization hold. Customer is responsible for understanding its particular financial institution’s policies regarding authorization holds and the specific effects on Customer’s financials. Customer also agrees to abide by Petra’s Standard Sales Terms and Conditions (found at www.petra.com/terms) and any other applicable terms and conditions set by Petra and available upon request by Customer. Customer hereby authorizes Petra to process payment for all orders made by fax, phone or email to the above-referenced credit card. These orders will be made by the above-listed authorized users. Any changes such as adding or deleting users will be made in writing to Petra. Customer assumes responsibility for payment. Authorized Signer_ ______________________________________________ Date_______________________________________ Printed Name of Signer Above________________________________________________ (*subject to auth. hold) PLEASE CHECK IF NEW CUSTOMER ORDER PENDING PAYMENT TERMS REQUESTED Credit Card (Fill out credit card information below) COD Cert. Funds By choosing this option, Customer agrees to assume responsibility for all freight charges for any shipment sent COD certified funds that is rejected or returned to Petra. True Value Corp. Billing By choosing this option, Customer states that Business is a True Value Store and that True Value Corporate is responsible for payment to Petra Industries, LLC. Ace Hardware Corp. Billing By choosing this option, Customer states that Business is an Ace Hardware Store and that Ace Hardware Corporate is responsible for payment to Petra Industries, LLC. COMPANY INFORMATION All invoices and statements are provided electronically to the Email addresses indicated in this box. If hard copies of these documents are required, a member of Petra's credit team may be contacted. Phone: 1-866-604-7287 • Fax: 1-866-604-7288 • www.petra.com Debit Card May be subject to an authorization hold by Customer's financial institution.
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