Principal CONTACT INFORMATION

* First Name

* Last Name

* Job Title

* Email

* Phone Number

Business Information

BILLING ADDRESS

* Country

* Address Line 1

Address Line 2

* City

* State/Province/Region

* Zip/Postal code

SHIPPING ADDRESS

My Shipping address is the same as my billing address

* Country

* Address Line 1

* Address Line 2

* City

* State/Province/Region

* Zip/Postal code

ACCOUNTS PAYABLE CONTACT

* First Name

* Last Name

* Email

* Phone Number

* Fax Number

* Requested Payment Option

COD Company Check

Open 30 Day Terms (includes two week memo service on certain items)

Pre-pay with a credit Card

REQUIRED DOCUMENT

ST-120 (Resale Certificate)

* ST-120 File

PDF or image file

Would you like to fax or email any of your missing documents ? Yes, I want to fax or email my missing document. I acknowledge that this will delay my account

Credit References

Credit Reference 1

* Company

* Company Contact First Name

* Company Contact Last Name

Account Number

* Phone Number

* Fax Number

Email Address

* Address Line 1

Address Line 2

* City

* State/Province/Region

* Zip/Postal code

Notes

Credit Reference 2

* Company

* Company Contact First Name

* Company Contact Last Name

Account Number

* Phone Number

* Fax Number

Email Address

* Address Line 1

Address Line 2

* City

* State/Province/Region

* Zip/Postal code

Notes

Credit Reference 3

* Company

* Company Contact First Name

* Company Contact Last Name

Account Number

* Phone Number

* Fax Number

Email Address

* Address Line 1

Address Line 2

* City

* State/Province/Region

* Zip/Postal code

Notes

Credit Reference 4

* Company

* Company Contact First Name

* Company Contact Last Name

Account Number

* Phone Number

* Fax Number

Email Address

* Address Line 1

Address Line 2

* City

* State/Province/Region

* Zip/Postal code

Notes

Guarantee of Terms and Condition

The Credit applicant(s) understand and agrees to the following terms and conditions:
Terms of sale are Net 30 Days on approved accounts.
All disputes and or returns must be made within 30 days of a items invoice date.
Damaged or gemstones that have been set will not be accepted for return.
It is understood that Finance charges will be applied to all past due invoices at the rate of 1.5% per month / 18% per year.
In the event that Stonemangems - Allan A. Goldman Inc. must access legal action to obtain moneys owed it is understood that the debtor will be responsible for any legal and or collection fees that are incurred as a result.
Any account payments or unapplied credits will be used to offset finance charges first before being applied to the oldest invoice(s).
Please be advised that invoices paid after the 30 day terms with a Credit Card will be accessed an additional 5% charge.
Copies of invoices may be subject to a $5. replacement fee.
A cash deposit or credit card authorization may be requested on incoming work if credit terms are not approved.
Customer agrees that a credit card given as Security for obtaining a line of credit with stonemangems - Allan A.Goldman Inc. will be used in the event that the account becomes past due.
Failure to comply with these terms and conditions will result in a loss of credit privileges without notice.

The information supplied in this application is warranted to be true and correct and given for the purpose of obtaining credit from
STONEMANGEMS - ALLAN A. GOLDMAN INC.

Having filled out the above application and agreeing with the above guarantee please sign and print below.

Do you agree to these terms?

Yes, I agree to these terms and conditions.

As the principal of the company having filled out the above application and agreeing with the above guarantee please sign and print below and fax to 212-869-3080 or scan and email to brad@stonemangems.com

Principal's individual signature

Title

Date

Principal's Printed Full Name

[] Please print this form and fax or email the signed LAST page before pressing Submit.

Stonemangems - Allan A. Goldman Inc.

Credit Application

Principal CONTACT INFORMATION

Business Information