________________________________________ _____________________________
Name of firm or individual
Fax Number
________________________________________ _____________________________
Address
Phone Number
________________________________________ _____________________________
City
State Zip
E-Mail Address
The following information must be completed in full, and will be held in the strictest
confidence, for the purpose of establishing credit with Horticultural Alliance, Inc..
___Corporation ___Partnership ___Sole Proprietor
_______________________________________________________________(____)___________
Name of Principal (s) Address
City
St ZIP
Phone
______________________________________________________________(____)_____________
Bank
Address
City
St ZIP
Phone
____________________________________________________________________________
Contact Account Number
______________________________________________________________(____)__________
Trade Reference Address
City
St ZIP
Phone
______________________________________________________________(____)__________
Trade Reference Address
City
St ZIP
Phone
______________________________________________________________(____)__________
Trade Reference Address
City
St ZIP
Phone
We certify that all the information listed above is correct and agree to the credit terms
of 2%/10 days, net 30 days. Accounts over thirty days will be charged 1.5% interest per
month, or the highest interest rate allowed by law. Should collection procedures become
necessary, reasonable collection and legal fees shall also be paid.
_______________________________________________________________
Date
Signature
___________________________________
Print Name
Title
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The entire contents of this document are ©
1997-2006, by Horticultural Alliance, Inc.
1550 66th Ave. Dr. East
Sarasota, FL 34243
800-628-6373, 941-739-9121
888-386-4478, 941-752-1890 Fax
DIEHARD™ and OneStep™ are trademarks and Horta-Sorb® is a
registered are trademarks and Horta-Sorb® is a registered
trade name of Horticultural Alliance, Inc. Sarasota, FL