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"*" indicates required fields BUSINESS CONTACT INFORMATIONCompany Name:* Subsidiary/Division of: Address:* Street Address PO Box: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number:*Phone Type:MobileOfficeCompany Website:* Date of Company's Establishment:* Month Day Year TIN/EIN:*Sales Tax Exempt?* Yes No Upload W-9 Form:* Drop files here or Select files Accepted file types: pdf, Max. file size: 2 GB. Please Submit Your Exemption Form(s)* Drop files here or Select files Accepted file types: pdf, Max. file size: 2 GB, Max. files: 3. Upload all that applyPO Required?* Yes No Credit Limit Requested:*Project Manager or Admin:* First Last Project Manager/Admin Phone Number:*Project Manager/Admin Email:* BUSINESS INFORMATIONOfficer/Owner Name:* First Last Officer/Owner Phone Number:*Officer/Owner Email:* Additional Officers/Partners:Full NameTitlePhone NumberEmail Add RemoveINVOICING INFORMATIONSend any specific invoicing instructions to [email protected]Accounts Payable/Billing Contact Person* First Last Contact's Phone Number:*Accounts Payable and/or Invoicing Email:* Project Administrator: First Last Contact's Phone Number:Contact's Email: BUSINESS/TRADE REFERENCESExcluding BanksCompany Name #1:* Address: (Company #1)* Street Address PO Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Company Name #2:* Address: (Company #2)* Street Address PO Box City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code AFFINITY ENERGY TERMS & CONDITIONSAcknowledgement* I authorize Affinity Energy LLC to verify the credit information provided on this form and contact the references listed above.I authorize Affinity Energy LLC to verify the credit information provided on this form and contact the references listed above. In the event credit is extended, the Applicant agrees to pay all costs and expenses, including actual and reasonable attorneys’ fees, incurred by Affinity Energy LLC collecting any amounts owed. If approved, the credit terms are Net 30. The Customer guarantees that the above information is accurate to the best of their knowledge, and Customer has read Affinity Energy LLC’s Terms and Conditions of sale attached as Page 2. The Customer agrees that any transaction between Affinity Energy LLC and the Customer and/or Applicant (collectively, “Buyer” in the Terms and Conditions) shall be governed by said Terms and Conditions, regardless of any other submittals by any party other than Affinity Energy LLC. GUARANTEE. I understand that Affinity Energy LLC is unwilling to extend or continue credit to the Applicant unless it receives my personal guarantee of payment of all liabilities, both currently existing and in the future, of Applicant to Affinity Energy LLC. Accordingly, for good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the undersigned Guarantor individually, irrevocably and unconditionally guarantees the prompt payment in full of all of the current and future obligations of Applicant to Affinity Energy LLC, including without limitation, its payment obligations under Affinity Energy LLC’s Terms and Conditions and any Affinity Energy LLC invoice, and any interest owning, along with any fees and costs incurred by Affinity Energy LLC enforcing its rights. The Guarantor hereby waives presentment, demand for payment, protest, notice of any kind, any other suretyship defense and any defense arising from the bankruptcy, insolvency, dissolution, or liquidation of the Applicant. This is a continuing guaranty of payment and not of collection. Affinity Energy LLC may assign this guarantee at any time without the consent of Guarantor. Without Affinity Energy LLC’s prior written consent, the Guarantor shall not directly or indirectly assign, pledge or transfer all or any part of its responsibilities in this Guarantee, and any assignment without Affinity Energy LLC’s written consent shall be void. To the fullest extent permitted by law, Guarantor shall pay the reasonable attorneys’ fees and costs incurred by Affinity Energy LLC in connection with the enforcement of this Guarantee.Signature*By signing below, I certify all information is true and correct to the best of my knowledge. Authorized Personnel Signature Job Title Date* MM slash DD slash YYYY Time* Hours : Minutes AM PM AM/PM CAPTCHA