
1. NAMEOFPARENTCOMPANY,IFSUBSIDIARY:
2. TYPEOFBUSINESS:
3. YRS.ATPRESENTLOCATION:
4. YEARESTABLISHED:
5. ISTHISBUSINESSINCORPORATED?Y/N
6. IFYES,INWHICHSTATE?
7. YOURUSUALPAYMENTSCHEDULEIS:
CreditCard 30DAYS 60DAYS
8. OWNER&OFFICERNAMES&ADDRESSES:
OWNER: _____________________________________________________
_____________________________________________________
_____________________________________________________
OFFICER:_____________________________________________________
_____________________________________________________
_____________________________________________________
OFFICER:_____________________________________________________
CREDIT APPLICATION
DateSubmitted:
DateApproved:
TaxID#:
Contact:
Phone:
Fax:
E-Mail:
Each invoice is due according to the following terms:
If not paid in full within 30 days, credit terms are subject to review
*Supermarket Parts Warehouse is hereby authorized to substantiate and
investigate the information contained on this application and to report
purchaser’s performance of this agreement as interested party as permitted
by law.
Credit is Reviewed Every 6 Months.
Alloftheaboveinformationwillbekeptcondentialandwillbeusedonlytomakeadeterminationofcreditworthiness.Iherebycertifythattheabove
informationiscorrectandshouldbereliedupontothestatedpurpose.IfurthercertifythatIfullunderstandthetermsofcreditasofferedbySupermarketParts
WarehouseInc.,andagreedtopromptpaymentinconsiderationofanyextendedcredit.Mysignaturebelowauthorizesreleaseofcreditinformationfromthe
abovelistedsources.
CREDIT CARD INFORMATION (IF NOT SEEKING
CREDIT TERMS ONLY)
TYPE:_______________________________________________
CARD#:_____________________________________________
EXPIRATIONDATE:___________________________________
BILLINGADDRESS: __________________________________
9. REFERENCES:
TRADE
COMPANY: __________________________________________
ACCOUNT#:_________________________________________
CITY/STATE:_________________________________________
PHONE: _____________________________________________
FAX:________________________________________________
COMPANY: __________________________________________
ACCOUNT#:_________________________________________
CITY/STATE:_________________________________________
PHONE: _____________________________________________
FAX:________________________________________________
BANK
BANK: ______________________________________________
ACCOUNT#:_________________________________________
CITY/STATE:_________________________________________
PHONE: _____________________________________________
FAX:________________________________________________
CONTACT:___________________________________________
By:
Print Name and Title
Signature
Signature (Individually)
CompanyName:
StreetAddress:
MailingAddress:
City:
State:
Zip:
E-MailAddress:
Fax or Sign-Up Online - 24 Hour Fax - (845) 436-7677
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