Company Name: 

Address:

City:

State:   

Zip:  

Billing Address:

City:

State:   

Zip:  

Telephone:

Fax:    

Type of Business:

Corporation 

Partnership

Proprietorship

Line of Business:

Number of Employees:

Fed. I.D. #: 

Year Established:

Estimated Annual Payments to Albion

$

Your Annual Sales

$

Line of Credit Requested

$ 

Name of Corp Officer (1)

Title:    

Name of Corp Officer (2)

Title:    

Name of Corp Officer (3)

Title:    

Name of Corp Officer (4)

Title:    

Accounting Contact:

Corporate Website:  

References:

Bank Name

Telephone: 

Address:

City:

State:   

Zip:  

Account Officer:

Account #:

Reference Name (1)

Contact:

Telephone:

Fax:

Reference Name (2)

Contact:

Telephone:

Fax:

Reference Name (3)

Contact:

Telephone:

Fax:

Albion Credit Terms:

Albion Healthcare Staffing, Inc. and Albion Staffing Solutions, Inc. invoices are due and payable upon receipt.  A finance charge of 1.5% per month will be charged on all undisputed invoices over 30 days unless alternative credit arrangements have been agreed to in advance in writing between yourselves and Albion.  Credit privileges subject to immediate suspension or revocation if any undisputed invoices are not paid within terms or if your balance due at any time exceeds Albion's approved credit limits.  In the event that it becomes necessary for Albion to refer to a collection agency and/or attorney, all reasonable legal fees to be paid by yourselves.

The undersigned certifies that the information shown above of this application to be true.  Further, I/We authorize Albion to whom this application is submitted, to investigate the references, statements or other data obtained from me/us or from any other source pertaining to our credit and financial responsibility.

The undersigned further agrees to the above credit terms and such other terms and conditions as are set forth in our Engagement Letter.