Company or Account Name *

Phone *

Email *

Billing Address *

City, State, Zip *

Ship-To Address *

City, State, Zip *

Business Type *

Corporation
Partnership
Sole-Proprietorship

Taxable *

Purchase Order # Required *

Employer Identification No. or Social Security No. *

Resale No. (If applicable)

Bank Name *

Address *

City, State, Zip *

Phone *

Email *

Contact Person *

References *

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Credit Reference 1

Company Name *

Contact Person *

Address *

City, State, Zip *

Phone *

Email *

Credit Reference 2

Company Name *

Contact Person *

Address *

City, State, Zip *

Phone *

Email *

Applicant agrees to the following terms:

1.Any claim, cause of action, suit or demand arising out of or related to this Agreement, or the relationship of the parties, shall be brought

exclusively in Minnehaha County, State of South Dakota, and the parties irrevocably consent to the exclusive jurisdiction and venue of

such court and waive any objections they may have at any time to such exclusive jurisdiction and venue.

2. Applicant authorizes Dakota Riggers to utilize the foregoing credit card for accounts sixty (60) days past due.

3. As a condition for the extension of credit, Applicant agrees to pay all Dakota Riggers’ costs and disbursements incurred in bringing legal actions to the collect indebtedness, including all reasonable attorney fees.

4. All accounts will be established as Net 30.

**In order for your application to be processed it is necessary that all of the information requested on the form be provided and that it be signed to show your agreement to our credit terms and to authorize us to investigate your references.

I agree to these terms *

I hereby authorize the release of all credit information requested by Dakota Riggers & Tool Supply, Inc.

If credit is granted I/we promise to pay bills when rendered as per your terms, including any finance/service charges at 1 ½% per month. Minimum finance charge is $2.50.

Authorized By *

Date time *

Title *

Email *

I agree that this serves as my digital signature and acceptance of all conditions outlined above. *

All information will be kept confidential.

Thank you for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Thank you for getting in touch!

We appreciate you contacting us. One of our colleagues will get back in touch with you soon!

Have a great day!

Application For Credit & Agreement To Terms

Credit Reference 1

Credit Reference 2

Thank you for getting in touch!

Thank you for getting in touch!

Pittsburg Alleghany