Business Information

Business Name *

Owner Name *

Purchaser Name *

Email *

Phone *

Business Address *

City *

State *

ZIP Code *

Shipping Address

(if different from above)

Shipping Address

City

State

ZIP Code

Trade References

Trade Reference #1 Business Name *

Contact Name *

Email *

Phone *

Address *

City *

State *

ZIP Code *

Trade Reference #2 Business Name *

Contact Name *

Email *

Phone *

Address *

City *

State *

ZIP Code *

Bank Reference

Bank Name *

Account # *

Contact Name *

Phone *

Address *

City *

State *

ZIP Code *

Credit Information

Amount of credit requested for a 30 day period *

Credit Card Type *

Cardholder Name *

Credit Card Number *

Expiration Date *

CVV *

Billing Address *

City *

State *

ZIP Code *

I, the undersigned cardholder, authorize the merchant (JMP Wood) to charge my credit card for purchases related to goods and services. I agree that my information may be saved by the merchant for future payments and understand that this can be revoked at any time with request.

Your Name *

Please initial for signature *

Date *

Terms & Agreements

For the purpose of inducing (“JMP Wood”) to extend credit for the purchase of goods and services, the undersigned (“Customer”) provides the information on the credit application (including the attached balance sheet and income statement, if requested) and authorizes JMP Wood to make such inquiries and utilize such resources as it deems appropriate to obtain information regarding Customer’s credit and financial history and responsibility, and for this purpose, authorizes and approves the release of all such information by the trade reference(s) and bank(s) listed above.

Customer acknowledges that JMP Wood may rely on the information provided above, and accordingly, represents and warrants that the information is complete, true, and accurately reflects the present financial condition of Customer.

Customer also agrees that the information submitted does not omit any material facts regarding its financial conditions, results of operations, or prospects. It is understood that JMP Wood may also utilize other sources of credit information that it considers reliable.

If credit is granted, and Customer later fails to pay any indebtedness to JMP Wood when due, becomes bankrupt, or is deemed by JMP Wood to be insolvent at any times, JMP Wood may declare the entire balance of the indebtedness in default, and in such event, the entire balance shall become immediately due and payable.

In the event of a delinquency or default, the Customer agrees to pay JMP Wood standard late charges allowed by law, plus reasonable collection costs and attorney fees that may be incurred by JMP Wood. If in the event that collection fees become necessary, the applicant willingly agrees to pay such fees.

JMP Wood reserves all right to reject any credit or trade application without cause, and termination of any open credit or trade account.

Unless otherwise agreed, JMP Wood standard terms are Net 30 days.

I hereby give authorization for my bank to release requested information and the all terms listed above is understood, agreed, and accepted by:

Your Name *

Please initial for signature *

Date *

Thanks for your submission.

We look forward to working with you. Our team will review your submission and be in touch shortly. Thank you!

Thanks for your submission.

We look forward to working with you. Our team will review your submission and be in touch shortly. Thank you!

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