| * Name: |
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| * Email: |
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| * Home Phone: |
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| * Work Phone: |
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| * Billing Address line 1: |
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| Billing Address line 2: |
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| * City: |
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| * Zip: |
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| Delivery Address (if different from above) |
| Delivery Address line 1: |
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| Delivery Address line 2: |
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| Delivery City: |
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| Delivery Zip: |
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| Start Delivery Date: |
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| Special Instructions: |
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| Questions and Concerns: |
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| TERMS AND CONDITIONS: |
1. All charges are due and payable in full upon receipt of monthly statements.
2. Holder(s) of account accepts full responsibility for all charges made to this account.
3. Holder(s) of this account agrees to pay all collection or legal fees required to collect payment on delinquent accounts. |
| * I agree to all terms and conditions above and understand this agreement is subject to the Federal Consumer Credit Collection Act. |