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Firm Name: Address:


South Central Company a GW Berkheimer Company lN P.O. Box 367 Columbus 47202


For the purpose ofestablishing open account privileges the undersignedfumishes the following information to South Central a GW Berkheimer Company Inc. www. southcentralco. com Tel: 812-376-3343 Fax: 8 12-376-0556

office use only:

Additional TradeName: AnticipatedMonthly Purchase: BusinessPhoneNumber:

Billing Address: Type of Business: Established: Date Business

Business Fax Number: Email Address: Taxable:( ) TaxExempt: ( ) If tax exempt,please attach tax exempt certificate. ( Corporation: ) ( Partnership: )LLC: ( )

If incorporated, in whichIncorporated: State _ Nameof Owners,Partnen, or Oflicers:

Name: Title:


proprietorship: ) (

( Limited partnership: )

Residence Address:

Home Phone:

Social Security#

Name of AccountsPayableRepresentative: Name and Location(s)of any other businesses owned: BnlqxtNc INpoRvrATIoN: Name of Bank: Address: SavingsAccount # CheckingAccount # Loan Account # Monthly Payments: PnnCpAL SUPPLIERS: Name: l. Branch: Telephone#: Bank Representative: How is Loan Secured? Balance:




2. 3. 4. 5.

Have you given any of the above a personalguaranty? If Branch of Division, locationof Home Office: Building: ( ) Leasing:( ) Buying: ( ) MonthlyPayment: _ Are purchase ordersrequired? YES ( ) NO ( ) Nameof LandlordAvlortgager: If so, to whom?

Is the buyer currentlyin a BankruptcyProceeding, hasthe buyer filed a Voluntary Bankruptcy, or

or had an Involuntarv Insolvencv Proceedins filed aeainst it within the last l4 vears?

judgmentsagainst buyer? Are you currentlya partyto any lawsuit,or arethereany outstanding the If the answeris yesto either,please explainon a separate sheet.

Pagel/2 TERMS CoNDITIoNS: is agreed buyerwill pay all invoices AND It the within stated termsandagrees all termscontained invoices to in supplied by sellerasmay be amended from time to time. ln the eventpa).mentis not timely made,the buyer also agrees pay a time-pricesdifferential to per charge(servicecharge)ofthe lesserof I t/zYo rnonth(18% per annum)or the maximum lawful rate on all overdueamountsand to pay all collectioncostsincurredby seller in enforcement the terms and conditionsof this agreement, of includingcouft costs,actualreasonable attorney'sfees and collection agencyfees,within the stardfids of the industry, but not lessthan 25Voof the unpaid amountor principal and accumulated servicecharge,all without relief from valuation andappraisement laws. Iflegal action becomes necessary eitherbuyer or seller,the buyer aggress this or any contemporaneous subsequent by that or agreement be will govemedasto validity, interpretation,construction,effect and all otherrespects laws ofthe Stateof Indiana. by Buyer further agrees that in the event legal action becomes necessary either buyer or seller,jurisdiction and preferredvenueshall remain in by BartholomewCounty, in the Stateof Indiana. Buyer further agrees that any line of credit desiredor approvedis not a limitation of liability, ald the undersigned expresslyagrees that it will for in be responsible valid charges excess a line ofcredit eitherdesired approved. or or Having obtained all necessary authority, the undersignedauthorizesseller and its agents,attomeys and employeesto investigatethe credit standing,financial circumstances responsibility of buyers and all owners,partners,and,/orofficers listed on tlle reverseside hereof, and and authorizes instructsall persons and having information concerningbuyer's credit standing,financial circumstances responsibilityto release and such information to seller, its agents, attomeys or employees. This includes, without limitation, authorization for seller and its agents, attomeys, employees request, and to obtain,and usefor all purposes which sellerdeems necessary, copy of any creditbureauor consumer a credit reportsfor the entities/persons listed hereinat any time. The buyer further grants to seller a security interest in buyer's equipment,contract rights, inventories,receivableand proceedsof salesas collateral secure buyer'sperformance to the ofall obligations.The buyerhereby appoints employee, any agent, attorney or ofseller asbuyer's attomeyin fact to endone arld file on behalfofbuyer any UCC I form to perfect or recordthe securityinterest. All ofthe information suppliedby buyer is correctto the bestofthe knowledgeofthe undersigned, tle buyer understands all goodsor and that purchased services from seller are subjectto all termsand conditionscontainedin this credit applicationand agreement all other termsand and conditions contained anyofthe seller'sinvoices. on

Buyer's Signature Title Date ("debtor)") by

"creditot''), and for good and valuable consideration,the receipt of which is hereby acknowledged,the jointly and severally,"if applicable",guarantee full and prompt paymentwhen due, whetherby accelerationor otherwise,of undersigned, the all past,presentand future indebtedness, obligations and liabilities of the debtor to the creditor, whether direct or indirect, joint or several, absolute contingent, or including costs all ofcollection,interest, attomey's and fees("obligations"). The undersigned waives acceptance the Guarantyand further waives all noticesand demandsof any kind, including, but not limited to, all of presentment, demands ofpayments and noticesof nonpa),ment, protestand dishonorof any ofthe Obligationsby the debtor. The undersigned further waives all noticesand, specifically, herebyconsents any extensions credit, acceleration, to of modifications, immaterial alterations,or renewals the Obligationsor changeof the rate of interesttherefrom andany notices,the acceptance any partial paymentsor the releaseof of of transfer ofany collateral the pay.rnent for ofthe Obligation. The undersigned also waivesany claim, right, or remedywhich suchguarantormay now haveor hereafteracquireagainsteh debtor that arises hereunder and-/or from the performanceby the guarantorhereunderincluding, without limitation, any claim, remedy, or right of subrogation, reimbursement, exoneration, contribution, indemnification,or participationin any claim, right or remedyof secured party againstthe debtor or paxtynow ahs or hereafteracquires,whetheror not suchclaim, right or remedyarisesin equity, under contract,by any securitywhich secured starue, undercommonlaw or otherwise. Guarantor and Co-Guarantor,if applicable, authorizes creditor to investigate Guarantor's and Co-Guarantor's penonal credit standing, financial circumstances responsibilityand authorizes and and instructsall personshaving informationconcemingGuarantor'sor CoGuarantor's credit standing, financial circumstancesand responsibility to release such information to creditor, its agents attomeys or employees. This includes, withoutlimitation,authorization sellerandits agents, for attorneys employees request, and to obtain,andusefor all purposes which creditor deemsnecessary, copy of any credit bureauor consumercredit report for the Guarantorand Co-Guarantorat any a tlme. This guarantyis a continuingguarantyofpayment, and shall inure to the benefit of Creditor flom the datehereonand shall remain in full force and effect until written notice of termination thereof has been receivedby Creditor by certified mail. Termination of the guaxantyby the undersigned shall not effect any ofthe guarantor'sobligationshereunderwith respectto indebtedness incurred prior to the termination. No delayon the paxtofthe Creditorin exercising ofCreditor'soptions, powers, rights,or partialor singleexercise any or thereofshallconstitute a waiver thereof. All of the Creditor's rights are cumulative ard altemative. Wheneverpossible, each provision of this guaranty shall be interpretedin such a manneras to be effective and valid under applicablelaw, but if any provision of this guarantyshall be prohibited by or invalidunderapplicable law, suchprovisionshallbe ineffective only to the extentof suchprohibition withoutinvalidating remainder the ofthe provision theremaining portions or ofthis guaranty. This guarantyshall inure to the benefit of the Creditor and its successors assignsand shall be binding upon tlre successors assigns, and and

jurisdiction and preferredvenue shall remain in Bartholomew County, Stateof Indiana. In WitnessWhereof,this documentis executed the on day of

UNcoNontoNALGuaRaNtv: In consideration the extensionof credit to of


(Personal Guarantor Signature Only)

(Personal Co-Guarantor Signature Only)


2 pages

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