I apply for a Charge Account and consent to the obtaining of such information as may be required from time to time in connection with credit applied for or for information to any credit reporting agency or person with whom the undersigned has any financial relations. Payment due on the 15th of the month. Penalty for late payment 49.36% per annum compounded monthly. Charges or payments after the date shown are not reflected in this statement. By submitting this form, I agree to keep my account current (within 30 days of invoice) and in good standing. I further agree that should collection or legal action ever be necessary for satisfaction of this account; I shall be responsible for all costs.
