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RUSSELL COUNTY
SOLID WASTE DEPARTMENT
137 HIGHLAND DR
PO BOX 1208
LEBANON, VA 24266
TEL: (276) 794-7826 FAX (276) 889-8011
APPLICATION FOR COMMERCIAL/BUSINESS CREDIT ACCOUNTS
Please type or print clearly
LEGAL COMPANY NAME ___________________________________________________________
Physical Address: __________________________________________________________________
Mailing Address: __________________________________________________________________
Phone(s): ________________________    Fax: ________________________
Accounts Payable Contact: _____________________________    Phone: _____________________
E-mail address: ____________________________________________________________________
Other Trade Name(s): _______________________________________________________________
Tax ID #: _________________________                                       Year Established: ________________
PRINCIPAL OFFICERS/OWNERS


Name: ______________________________________ Title: ________________________
Resident address: __________________________________________________________
Phone: ______________________


Name: ______________________________________ Title: ________________________
Resident address: __________________________________________________________
Phone: ______________________


Name: ______________________________________ Title: ________________________
Resident address: __________________________________________________________
Phone: ______________________


RUSSELL COUNTY
SOLID WASTE DEPARTMENT
137 HIGHLAND DR.
PO BOX 1208
LEBANON, VA 24266
TEL: (276) 794-7826 FAX (276) 889-8011
APPLICATION FOR COMMERCIAL/BUSINESS CREDIT ACCOUNTS
Please type or print clearly
LEGAL COMPANY NAME
Physical Address:
Mailing Address:
Phone(s): Fax:
Accounts Payable Contact: Phone:
E-mail address:
Other Trade Name(s):
Tax ID #: Year Established:
PRINCIPAL OFFICERS/OWNERS

Name: Title:

Resident address:
Phone:

Name: Title:

Resident address:
Phone:

Name: Title:

Resident address:
Phone:
BANK REFERENCE


Bank Name: _____________________________ Business Checking Account No. _______________
Branch Phone No. _______________________


CREDIT REFERENCES


Name: _______________________________________ Account #: ___________________________
Address: _________________________________________ Phone/Fax: _______________________
City/State/Zip: _____________________________________ Contact: _________________________


Name: _______________________________________ Account #: ___________________________
Address: _________________________________________ Phone/Fax: _______________________
City/State/Zip: _____________________________________ Contact: _________________________


Name: _______________________________________ Account #: ___________________________
Address: _________________________________________ Phone/Fax: _______________________
City/State/Zip: _____________________________________ Contact: _________________________


All statements made herein are true and correct to the best of my knowledge.  We authorize Russell
County to make any and all inquiries necessary for evaluation of this applicated we indemnify Russell
County and its agents from any and all liability resulting from their survey.  Further, we hereby authorize
the bank and trade references listed in this credit application to release information necessary to assist
Russell County in establishing an account for us.
I hereby apply to Russell County Solid Waste Department for establishment of a charge account at the
Russell County Solid Waste Transfer Station and certify that I am empowered by the applicant to sign and
incur debt, and agree to pay Russell County when invoices are submitted.  PAYMENT TERMS: Net 30

Printed Name      Title

Signature      Date
BANK REFERENCE

Bank Nam

Business Checking Account No.
Branch Phone No.
CREDIT REFERENCES

Name: ‘Account #t
Address: Phone/Fax:
City/State/Zip: Contact:
Name: Account #:
Address: Phone/Fax:
City/State/Zip: Contact:
Name: ‘Account #:
Address: Phone/Fax:
City/State/Zip: Contact:

All statements made herein are true and correct to the best of my knowledge. We authorize Russell
County to make any and all inquiries necessary for evaluation of this applicated we indemnify Russell
County and its agents from any and all liability resulting from their survey. Further, we hereby authorize
the bank and trade references listed in this credit application to release information necessary to assist
Russell County in establishing an account for us.
hereby apply to Russell County Solid Waste Department for establishment of a charge account at the
Russell County Solid Waste Transfer Station and certify that | am empowered by the applicant to sign and
incur debt, and agree to pay Russell County when invoices are submitted. PAYMENT TERMS: Net 30
Printed Name Title
Signature Date
ACCOUNT TERMS AND AGREEMENT
The undersigned hereby makes application for credit from RUSSELL COUNTY.  The undersigned
agrees to the following terms of payment:


The monthly statements shall be due and payable within 30 days from the Billing Date.


The undersigned agrees to cost of collection including a reasonable attorney’s fee, and


interest accruing at the rate of (18%) per annum on all amounts past due.

This document shall be considered to have been executed in Russell County, Virginia

and the undersigned shall agree that it be governed and construed in accordance with
the laws of the Commonwealth of Virginia.

The undersigned agrees that written notice shall be given to Russell County of any billing

ticket or statement errors within fifteen (15) days of the date thereon.

The fact that this application contains a request for an estimate of monthly credit

required shall not be deemed a limitation of liability by the undersigned or any
guarantor.

The undersigned acknowledges and agrees that credit checks may not be limited to the

references listed on this application.

If the applicant is a corporation, the person signing the application on behalf of the

applicant warrants that he/she is authorized to do so.  If the applicant is not a
corporation at the time of the application, and subsequently incorporates his/her
business, with or without the knowledge of Russell County, the applicant agrees to be
jointly and severally liable to Russell County for any indebtedness incurred by or
transferred to such corporation.

The undersigned agrees to provide Russell County with prior written notice of any

change in the business structure (e.g. incorporation, change of ownership, etc.).  Any
such notice shall be mailed by certified or registered mail, return receipt requested, and
shall be effective after the expiration of five (5) days after the date such notice is
received by Russell County.  Without such notice, the original principals to whom credit
was extended shall remain liable under the terms of this credit application.
Signature ___________________________________________   Date ________________
Authorized Agent  Title
Signature ___________________________________________   Date ________________
Authorized Agent  Title
ACCOUNT TERMS AND AGREEMENT
The undersigned hereby makes application for credit from RUSSELL COUNTY. The undersigned
agrees to the following terms of payment:


The monthly statements shall be due and payable within 30 days from the Billing Date.


The undersigned agrees to cost of collection including a reasonable attorney’s fee, and
interest accruing at the rate of (18%) per annum on all amounts past due.


This document shall be considered to have been executed in Russell County, Virginia
and the undersigned shall agree that it be governed and construed in accordance with
the laws of the Commonwealth of Virginia.


The undersigned agrees that written notice shall be given to Russell County of any billing
ticket or statement errors within fifteen (15) days of the date thereon.


The fact that this application contains a request for an estimate of monthly credit
required shall not be deemed a limitation of liability by the undersigned or any
guarantor.


The undersigned acknowledges and agrees that credit checks may not be limited to the
references listed on this application.


\f the applicant is a corporation, the person signing the application on behalf of the
applicant warrants that he/she is authorized to do so. If the applicant is not a
corporation at the time of the application, and subsequently incorporates his/her
business, with or without the knowledge of Russell County, the applicant agrees to be
jointly and severally liable to Russell County for any indebtedness incurred by or
transferred to such corporation.


The undersigned agrees to provide Russell County with prior written notice of any
change in the business structure (e.g. incorporation, change of ownership, etc.). Any
such notice shall be mailed by certified or registered mail, return receipt requested, and
shall be effective after the expiration of five (5) days after the date such notice is
received by Russell County. Without such notice, the original principals to whom credit
was extended shall remain liable under the terms of this credit application.


Signature Date
‘authorized Agent Title
Signature Date
“authorized Agent Tie