| Company Name: |
|
| Address: |
|
| Tax ID#: |
D&B # |
| State Incorporated |
Parent Company (if applicable) |
| Purchase orders required Yes / No |
|
| BANK REFERENCES |
|
| Bank Name |
Bank Address |
| Contact Name |
|
| Bank Phone |
Bank Fax |
| TRADE REFERENCES |
|
| Company Name |
Contact Name |
| Address |
|
| Phone |
Fax |
|
|
| Company Name |
Contact Name |
| Address |
|
| Phone |
Fax |
|
|
| Company Name |
Contact Name |
| Address |
|
| Phone |
Fax |
PAYMENT TERMS
Balance is due in full by the 10th of the month for any purchases made the prior month. I hereby agree to pay 2% per month service charge on past due balances. Further, I agree that I will be liable for attorney and collection fees which may be reasonably incurred in order to collect any amounts owed.
In order to induce Late Model Import to grant credit, the undersigned agrees to the need for verification of the information listed on this application. The undersigned hereby authorizes the release of information by all banks, businesses and individuals identified on this application.
| Applicant Signature |
Date |
| Printed Name |
Title |
|
