House Account Application

Please fill out this application and email it by clicking on the submit button when you have finished.

Company Information:
Company Name:
Office Address:

City:
State:
Zip:

Billing Address:

City:
State:
Zip:


Phone #:
Fax #:
Contact:
E-mail:
Federal Tax ID No.:
Names of Authorized Account Users:
1.
2.
3.
4.
Credit References:
Name of Business:
Phone Number:
Account Number:


Name of Business:
Phone Number:
Account Number:

Name of Business:
Phone Number:
Account Number:
Bank Information:
Name of Bank:
Branch:
Phone Number:
City:
State:
Zip:
Account Number:
Today's Date:
Digital Signature:
By typing your name and submitting this application you hereby agree to the terms below.

Terms of Agreement: In consideration of the granting and extension of credit by Bertrand's Bistro to the undersigned it is hereby agreed that the undersigned will promptly pay all sums when due. In the event of non-payment, the undersigned does hereby agree to pay in addition to the principal amounts due, reasonable attorney fees and court costs. Balances unpaid over 30 days are subject to a 2% per month service fee.

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