|
NOTE:
Fields with * are required
|
| Business
Name:* |
| Business
Address:* |
| City,
State & Zip:* |
| Shipping
Address if different: |
| Business
Phone:* |
Fax
Number: |
| Sales
Tax Number:* |
Years
in Business:* |
| Email
Address : |
| Name
of Parts Buyer:* |
| A/P
Name:* |
|
Type
of Business:*
(_)
Sole Proprietorship (_) Partnership (_) Corporation
Other:
______________________________(_)
|
| Purchase
Order Required?*
(_) Yes (_) No |
| Do
you want Backorders?*
(_) Yes (_) No |
|
|
Information
on Business Owners or Officers
|
| Name
& Title:* |
| Residence:* |
| City,
State & Zip:* |
| Home
Phone:* |
| Name
& Title: |
| Residence: |
| City,
State & Zip: |
| Home
Phone: |
|
|
Please
Check all that apply to what best describes your business
|
| Is
your business:*
(_) Dealership (_) Parts House (_) Repair Shop |
| For:*
(_) Motorcycle (_) Snowmobile (_) Off-Road (_) Trailer
|
|
Brands
Sold:*
|
|
|
Please
name two trade suppliers you use that are in our business
|
| Name:* |
Name:* |
|
|
Terms
|
| In
consideration of you extending credit to the above names
firm at my/our request, I/we hereby personally guarantee
payment of all obligations to you until withdrawn by me/us
by certified mail. |
| Dated*
this _____ day of ________________________________________,
20________ |
| Signed:* |
| Signed: |
|
|
The
remainder of this form is for open account applications only
|
|
Please
List three credit references and one bank reference
- no personal references
|
| Name:* |
| Street:* |
| City,
State & Zip:* |
| Account
Number:* |
| Phone
Number:* |
| Fax
Number:* |
|
| Name:* |
| Street:* |
| City,
State & Zip:* |
| Account
Number:* |
| Phone
Number:* |
| Fax
Number:* |
|
| Name:* |
| Street:* |
| City,
State & Zip:* |
| Account
Number:* |
| Phone
Number:* |
| Fax
Number:* |
|
| Name:* |
| Street:* |
| City,
State & Zip:* |
| Account
Number:* |
| Phone
Number:* |
| Fax
Number:* |
|
|
Terms
of Credit
|
|
Applicant
agrees that all credit extended pursuant to this application
shall be on the following terms and conditions: (1)
All account balances are due on or before the tenth
of the month following the purchase. (2) Any invoice
not paid on or before said date will be considered delinquent
and will bear interest at the rate of 1.5% per month
from the due date (3) The applicant shall pay all costs
of collection including reasonable amount of attorney's
fees on both the principal and the service charge.
It
is further understood and agreed that all orders placed
by debtor or myself and accepted by Automatic Distributors,
Inc. shall be consummated in Bangor, Maine and shipped
therefrom. It is also agreed that the enforcement of
any obligation arising from the extension of credit
pursuant to this application or from any order placed
by debtor or myself and accepted by Automatic Distributors,
Inc. will be under the jurisdiction of the State of
Maine and Maine laws shall govern such proceeding.
|
| Read,
acknowledged & Accepted:* |
| Dated:* |
|
|
Customer
Consent & Authorization
|
| *
I,
________________________________________________________________________
Name
of owner / officer
|
| *
of
_______________________________________________________________________
Business
Name
|
|
Address:
* |
| City,
State & Zip: * |
| Hereby
Authorize :*
Name
of bank
|
|
Address:* |
| City,
State & Zip:* |
| to
disclose financial records concerning the following: |
| Account
Number:* |
Type
of Account:* |
| Account
Number:* |
Type
of Account:* |
| Account
Number:* |
Type
of Account:* |
| To
Automatic Distributors, Inc. for the following purpose(s):* |
(_)To
establish an open line of credit
|
(_)To
update records
|
(_)
Other:
|
| I
understand that this Authorization may be revoked by me
in writing at any time before my records, as described
above, are disclosed; and that this Authorization is valid
for no more than three (3) months from the date of my
signature. |
| Customer
Signature:* |
| Date:* |
|
