Credit Application

12320 Oracle Blvd. #310 Colorado Springs, CO 80921

Email: ssccollections-bw@medianewsgroup.com

SSN / FEIN:

Company (Complete legal name of entity. If corporation, use exact corporate name)

DBA	Telephone No.

Billing Address	City	State	Zip

Telephone No.	Fax No.	Contact Person	Title

If company is a subsidiary, name of parent company

Nature of Business	Years in Business

Type of Business	Proprietorship	Corporation	Partnership	LLC Estimated Advertising per month $

Personal Information on Officers, Partners or Guarantors

Name	Title	% Owner	Social Security No.
Home Address	City	State	Zip	Home Phone No.
Name	Title	% Owner	Social Security No.
Home Address	City	State	Zip	Home Phone No.
Name	Title	% Owner	Social Security No.

Home Address	City	State	Zip	Home Phone No.

Media References

Name	City/State	Telephone No.	Account No.
Name	City/State	Telephone No.	Account No.

Suppliers

Name	City/State	Telephone No.	Account No.
Name	City/State	Telephone No.	Account No.

Bank References

Name of Bank/Branch	City/State	Chkg. Acct. #	Telephone No.	Contact Person
Name of Bank/Branch	City/State	Chkg. Acct. #	Telephone No.	Contact Person

Credit Agreement

Customer verifies that the above information is true and correct and authorizes any person to release information to the 21st Century Media. Customer agrees to pay attorney’s fees and collection costs incurred in the collection of any delinquent account. Customer also agrees to pay for any and all advertising placed under its accounts, whether authorized by the customer or any person on his behalf. All changes in the Ownership or management of the customer and any matter concerning the extension of credit or payment of a debt must be communicated to the credit manager or his/her assistant in writing. I, we further agree, that should it be necessary for the 21st Century Media to institute any Legal proceedings for the collection of any balance due under this account, to pay reasonable attorney fees to be fixed by the court therein and All costs of suit.

All Accounts are due and payable on the 15th of the month following publication.

Signature / Title must appear here	Your signature on the application is also Authorization for the bank to release the Information requested.
Type or print signature name and title here	Date:

Credit Authorization and Guarantee

I, we, hereby authorize the 21st Century Media to insert and publish those advertisements pertaining to out business. This account will be

handled by ________________________________ agency and we also personally guarantee payment as individuals in accordance with

established BayAreaNews Group credit terms. Any change or cancellation must be in writing on file in the credit office of the BayAreaNews

Group.

Signature	Date

Sales Representative	Publication

Phone #	Account #