Form

Apeiron Clean Logo-1

Credit Application Form

Please complete the online form.

This credit application will help us to evaluate your credit. Please complete all the fields to help us with the credit decision.

Business Information

Legal Name*

What is the company legal name?

Trade Name*

If the company is traded under a different name, type it here otherwise type 'same'.

Parent Company*

What company (if any) has controlling interest in your company? Indicate 'not applicable' if this does not apply.

Business Description*

How would you best describe your company? Sole Proprietorship, Partnership, Corporation or Division/Subsidiary? Select from the dropdown.

Billing Address*

Street Address, City, State/Prov, Country and Postal Code

Shipping Address*

Street Address, City, State/Prov, Country and Postal Code

Business Details

What type of business*

Briefly describe your business

Number of Employees*

Years in Business*

Company Phone Number*

Fax Number*

GST#/ Fed Tax ID Number*

GST# (Canada) or Federal Tax ID# (US)

PST#/ State Tax ID#

What is your Sales Tax#? Upload a copy of your exemption certificate if applicable.

D&B #

Rent/Own Premises?*

Annual Sales*

Net Worth*

Company Website URL*

What is your company website URL?

Credit Limit Required*

How much credit do you require?

Bank Details

Bank*

What is the name of your bank and division?

Account No.*

What is your bank account number?

Bank Address*

Street Address, City, State/Prov, Country and Postal Code

Manager/Bank Contact*

Who is your bank manager or primary contact at the bank?

Bank Phone Number*

Bank Fax Number*

Accounts Payable Details

AP Contact - First name*

AP Contact - Last name*

AP Contact Email*

AP Contact - Phone number*

AP Contact - Fax number

PO Required?

Payables Email Address

If different from the above contact details

Sharehold/Partner Details

Shareholder Details (1)*

Please provide full name, title, home address and phone number

Shareholder Details (2)

Please provide full name, title, home address and phone number

Shareholder Details (3)

Please provide full name, title, home address and phone number

Trade References

Trade Reference (1)*

Name, Telephone and Fax Number required.

Trade Reference (2)*

Name, Telephone and Fax Number required.

Trade Reference (3)*

Name, Telephone and Fax Number required.

Additional Comments

Is there anything else that would help us in our decision?

File Upload

Terms & Conditions

The Applicant acknowledges that at present, the Company’s standard TERMS OF SALE are Net 30 days with FOB Origin. Past due accounts will be subject to a late payment charge of 2% per month, and this policy is subject to change without notice. Payment Terms will be calculated from the invoice date. Terms cannot be varied except in writing by a duly authorized officer of Apeiron Energy Inc. All customers applying for a credit account may have to supply a credit card to ship their order while application is in for approval.

If the Applicant fails to abide by the TERMS OF SALE contained herein, Apeiron Energy reserves the right to discontinue and eliminate any price discounts or sales incentives offered to or in place with the Applicant, both retroactively and for future sales unless otherwise negotiated by the parties. Deductions from payments for any reason will not be allowed unless Apeiron Energy has issued a credit memo. All incentive and credits issued by Apeiron Energy are personal to the account holder and are not transferable or assignable. Apeiron Energy may refuse to ship any confirmed order in whole or in part for any reason it deems sufficient. Upon default all accounts with the customer become immediately due and payable, including stopping goods in transit.

Applicant’s signature attests financial responsibility, ability, and willingness to pay all billings in accordance with current terms. In the event the services of a collection agency are necessary, customer agrees to pay all collection costs. Should legal means become required to collect monies owed, customer agrees to pay all legal and attorney and collection charges, in connection therewith, including court costs. Customer knowingly and intentionally waives the right to a jury trial on any issue that may arise.

Name of Authorized Signing Officer*

Title of Authorized Signing Officer*

E-Signature of Authorized Signing Officer*

Electronic Signature Agreement

By selecting the "I Accept" button, you are signing this
Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Apeiron Energy. You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement.

Application Instructions

Please attach all financial statement(s), personal financial statement(s), and other pertinent information to expedite credit processing.
Include history of management experience for owners and/or shareholders
Include other information useful for the evaluation of credit (ie. additional assets, financial backing, etc.)