Terms and Credit Request

Use this form to request payment terms or an account credit review for your business. Provide your business name, DCC license number, requested terms (e.g., Net 7/Net 14), and any supporting info (purchase history, references, or preferred payment schedule). Submitting this form does not guarantee approval—our team will review and follow up with next steps. If you’re requesting changes to existing terms, include your current terms and invoice numbers.

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Legal Business Name *

DBA (If different than Legal Business Name)

($) Payment +

Entity Type *

• LLC
• Corp
• Sole Prop
• Partnership

DCC License # *

Sellers Permit # *

Website URL

Primary Buyer Name *

First

Last

Primary Buyer Numbers *

Primary Buyer Email *

Account Payable Name *

First

Last

Account Payable Number *

Accounts Payable Email *

Requested Terms *— Select Choice —Net 7Net 15Net 30

Requested Credit Limit *

Estimated Monthly Volume ($) *

Payment Method

• Cash
• ACH
• Check

Reference – Bank Name *

Reference – Company Name + Contact + Phone *

Consent

• I certify the information is accurate and authorize The Humboldt Cure to verify references

Agreement

• By checking this box I agree the above is correct to the best of knowledge and agree to enter a credit agreement with Humboldt Cure Inc.

Submit