Account Application | Maine Oxy | Specialty Gases and Welding Supplies

Application for Account Privilege

Type of Account Applied for

Charge
Cash on Delivery (COD)

Limit Desired

Billing Information

Company Name

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Shipping Information

Same as Billing

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Details

Phone

SIN or TIN

Account Type

Individual
Company

Date of Birth

Individuals Only

Fax Number

Untitled

Taxable
Exempt (Indicate type)

Tax exempt status relies on receipt of certificate. Please upload file below.

Tax Exempt Documentation

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 32 MB, Max. files: 3.

Purchase Order Required?

Yes
No

Method of Invoicing

Fax
Email
Mail

Email

Authorization

TERMS: 30 DAYS FROM THE DATE OF INVOICE. SERVICE CHARGES OF 1.5% A MONTH WILL BE CHARGED ON OVERDUE ACCOUNTS The Corporation and/or I agree that title to cylinders will remain solely with MaineOxy. If it becomes necessary to refer the account to a lawyer or a collection agency due to non-payment of the buyer, any collection or legal fees will be the responsibility of the undersigned buyer and/or the corporation. The signature below authorizes MaineOxy to run a credit report (for charge accounts) to obtain information necessary to complete this application for account privilege. This agreement constitutes a security interest in the equipment which are the subject of thereof. Lessee grants a security in, and a general lien upon the equipment and proceeds thereof. The lessee agrees to cooperate with the Lessor and expressly permits Lessor to execute and file financing statements and take such other actions as shall be required to perfect the Lessor’s security interest in the Equipment in accordance with this agreement.

I agree to the above terms.*

I agree

Date

Signature

Printed Name