Non Dealer Credit Application Form

1. Insert Legal Name & Logo Here
NON-DEALER CREDIT APPLICATION
Company Name ____________________________________________ ID# (i.e. FID# in the US)_______________
Product Line Type (being applied for): ________________________________________________________
Street __________________________
Phone # (____)_____________ Fax # (____)_______________
City __________________________
State/Providence ___________
Corporation [
]
LLC [
]
Partnership [
]
Zip ______________
Proprietorship [
]
BANK REFERENCE
Bank ___________________________________________ Branch ________________________________
Address ________________________Telephone (_____)________________Fax (____) _________________
Contact _______________ Email _______________________________ Checking [ ] Loan [ ] Savings [ ]
Bank ___________________________________________ Branch ________________________________
Address ________________________Telephone (_____)________________ Fax (_____) _____________
Contact _______________ Email _______________________________ Checking [ ] Loan [ ] Savings [ ]
TRADE REFERENCE
Name
City & State/
Providence
Contact
Email
Fax #
Telephone
________________________________________________________(_____)___________(_____)______________
________________________________________________________(_____)___________(_____)______________
________________________________________________________(_____)___________(_____)______________
________________________________________________________(_____)___________(_____)______________
________________________________________________________(_____)___________(_____)______________
________________________________________________________(_____)___________(_____)______________
I authorize the above bank and business references to give any and all necessary information to you which will assist
you in your credit inquiry. I release any claim I have for breach of contract or invasion of privacy because of
information furnished. This application is given for the purpose of obtaining credit. In the event of any material
change in our financial condition, we will notify you immediately in writing.
Name (print) ______________________________
Date ______________________________
PLEASE RETURN TO: ATTN: CREDIT CONTACT
LEGAL NAME
MAILING ADDRESS
Signature _________________________________
Title ____________________________________
Ph. Fax E-mail
Rev7/13

2. Contact Information
Accounts Payable Contact ___________________ Email Address ______________________
Phone (
) ________________________ Mobile (
) _____________________________
All of our documents are emailed rather than mailed. Identify what name/email addresses you would like
these specific documents to go to (there can be more than one for each)
Name
Email
1. Warranty Credit Memos: ____________________________________________________
2. Credit Memos: ____________________________________________________________
3. Invoices: _________________________________________________________________
4. Customer Statements:_______________________________________________________
5. Sales Order Confirmations: __________________________________________________
6. Accounts Payable Contact: __________________________________________________
PRINCIPAL OWNERS
FIRST, MI,
LAST NAME
TITLE
CITY / STATE or Prov
SS #
% OWN
SPOUSE
NAME
____________________ __________ _______________ ___________ ______ ___________
____________________ __________ _______________ ___________ ______ ___________
____________________ __________ _______________ ___________ ______ ___________
____________________ __________ _______________ ___________ ______ ___________
Rev7/13