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OfficeCoffeeIcon.com and Southern Refreshment Services Inc.
Credit Application

This form is encrypted to insure that this information is secure. Your information will never be sold or given away. Please read our our privacy policy if you have any concerns. If you would prefer to mail or fax your application, you can download the printable version of it.

Please Note: Applying for credit on OfficeCoffeeIcon.com does not register you as a user on OfficeCoffeeIcon.com. You will still need to register to create an account with OfficeCoffeeIcon.com.

Company Name:

DBA (if different):

Contact Name:

Address Line 1:

Address Line 2:

City:

State:

Postal Code:

E-Mail Address:

Phone Number:

Fax Number:

Federal Tax ID or Social Security Number:

Type of Business:

Date business established:

No. of employees:

Amount of Credit Requested:

Authorized Purchasers

Type of Products you plan to purchase:

Coffee Supplies	Cleaning Supplies
Coffee Equipment	Keurig Products
Hotel Room Coffees	First Aid Products
Other

Are you sales tax exempt?

Yes No

Have you ever had Credit with us before?

Yes No

If yes, under what name:

Purchase order required?:

Yes No

Are you a:

CORPORATION
PARTNERSHIP
SOLE PROPRITORSHIP

Corporation & Partnership Information
If you are chose Sole Proprietorship, skip this section. If you are a Corporation or a Partnership, then please fill out the fields that are applicable to your type of business.

#1 Chief Corporate Officer or Partner

Name:
Title:
Address:

#2 Chief Corporate Officer or Partner

Name:
Title:
Address:

#3 Chief Corporate Officer or Partner

Name:
Title:
Address:

Resident Agent (Corporation Only)

Name:
Address:

State of Incorporation (Corporation Only)

Trade References

Reference #1

Name:
Phone:
Address:

Reference #2

Name:
Phone:
Address:

Reference #3

Name:
Phone:
Address:

Bank References

Bank #1

Account#:
Phone:
Contact Person:
Name of Bank:
Address:

Bank #2

Account#:
Phone:
Contact Person:
Name of Bank:
Address:

This company is applying for credit with OfficeCoffeeIcon.com and Southern Refreshment Services INC. And agrees to abide by the standard terms and conditions.

GENERAL TERMS AND CONDITIONS AND PERSONAL GUARANTEE

Bills are to be paid net 10. 10 days from the billing date.
All bills become payable in full on the 11th day and if not paid by the end of the 11th day they are considered past due.
An interest penalty charge of 2% per every 20-day period will be added to all amounts billed, if not paid by the end of the first 20 days.
No additional credit will be extended to past due accounts unless satisfactory arrangements are made with Southern Refreshment Services INC. credit department 1-866-377-2962.
PERSONAL GUARANTEE: If the credit customer is a corporation, then whether signing as an officer or not, personally guarantee payment for all items purchased on credit by the corporation.

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The Keurig Company only authorizes OfficeCoffeeIcon.com to sell Keurig brewers and Keurig products for commercial use in Texas and Louisiana. For Keurig or K-cup products for home use in the U.S. please visit our other website www.CoffeeIcon.com.