Supplier Name	Supplier Address	Phone/Fax

I/We

And

Of

apply to you for credit for the supply of service and materials in accordance with the application for credit concurrently made. I/We will jointly and severally indemnify you, and see you paid for your account with respect to any order now or hereafter made by any of us. I/We further agree to pay the account within established terms and to pay service charges on overdue accounts. I/We understand and consent to you obtaining a consumer report containing personal and/or credit information in connection with this transaction.