- Modern Lane

Modern Lane Credit Application

Business Information

Legal Business Name

Federal Tax ID

D&B Number

Business Type

Years in Business

Payment Method

Credit Card

ACH

Check

Business Address

Street Address

City

State

Zip Code

Correspondence

Phone Number

General Emails

Invoice Emails

Statement Emails

Owners / Officers

Bank Reference

Bank Name

Contact Name

Phone

Address

Account Type: Checking Savings

Trade References

Additional Stores

Tax Information

Tax Exemption Certificate (Optional)

Agreement

I certify that the information provided is accurate and complete.

This application is submitted for the purpose of obtaining credit with Modern Lane, LLC, and is warranted to be true. By signing this application, the undersigned acknowledges that he/she is authorized to execute this application and to obligate the company to make payments in full for all amounts due according to the invoice on or before the net due date. Additionally, the undersigned will be responsible for all collection costs and attornoey fees, with or without lawsuit and or arbitrations, in order to collect delinquest past due balances. The undersigned hereby authorizes Modern Lane, LLC, to make such inquiries (corporate/personal) as necessary to obtain credit information and authorizes the bank(s) of record to release information regarding any accounts listed above.

Signature

Authorized Representative Name

Electronic Signature