|
|
Parts Credit Application
|
Trade Name
|
Legal Name
|
Physical Address
|
City
|
State
|
Zip
|
Billing Address
|
City
|
State
|
Zip
|
Former Address (5 yr Min)
|
City
|
State
|
Zip
|
Job Site Address
|
Job Site Phone #
|
Type Business
|
Date Business Started
|
State of Incorporation
|
Phone #
|
Fax #
|
Fed ID#
|
Corporation
LLC Corp
Partnership, LP, or LLP
Proprietorship
|
Home Address:
|
Social Security
|
Cell Phone
|
E-Mail Address
|
Home Office/Parent Co.
|
City/State
|
Website Address
|
Name & Title of Contact
|
MC# if Applicable
|
| Company Principles: |
Principle
|
Title
|
Principle
|
Title
|
Bonding Company
|
Phone
|
|
Have you ever taken BANKRUPTCY?
Yes
No
|
When?
|
Explain:
|
Bank Name & Branch
|
Address
|
City/State/Zip
|
Account #
|
Telephone
|
Account Bank Officer
|
Estimated Monthly Credit Requirements
|
|
Subject To Purchase Orders?
Yes
No
|
Authorized Person To Issue PO:
|
|
Credit limits are based on information received from credit references. Please provide your largest unsecured creditors. List name, complete address and telephone number of five companies from whom purchases are made on open account. Please list references
related to your type of business or industry. (No oil companies or credit cards please.)
|
Company
|
City
|
State
|
Phone
|
Fax
|
Company
|
City
|
State
|
Phone
|
Fax
|
Company
|
City
|
State
|
Phone
|
Fax
|
Company
|
City
|
State
|
Phone
|
Fax
|
Company
|
City
|
State
|
Phone
|
Fax
|
|
Rented / Leased equipment in the past?
No
Yes
|
From Whom? Company Name
|
Address
|
Phone
|
The above information is given for the purpose of obtaining credit and is warranted to be true. We affirm that we are financially able to meet our obligations, and will remit in accordance with the invoice terms. I/We hereby authorize all of the above named persons or companies to release to Regions interstate Billing Service, Inc., or it representatives, such information with regard to my/our financial condition as may reasonable have a bearing on this application. I/We authorize Regions Interstate Billing Service, Inc. to obtain a consumer credit report on my/our personal credit history if necessary, in accordance with the Federal Fair Credit Reporting Act, and to use this report in making decisions concerning my/our credit worthiness for a 30-day account. I/We understand a personal guaranty may be required. If I/We refuse to sign this application, I/We will not be considered as a candidate for credit with Regions Interstate Billing Service, Inc. A credit limit may be established at our discretion. Applicant agrees to pay any collection costs incurred to collect the unpaid balance, including interest on the unpaid balance, as allowed by state law, and any reasonable attorneys fees.
Your account has been assigned to Regions Interstate Billing Service, Inc. Make checks payable to the vendor(s). Please mail all payments c/o Regions Interstate Billing Service, Dept. 1265, P.O. Box 2153, Birmingham, AL 35287-1265. Payment terms will be reflected on the monthly statement and/or invoice. If your business should sell or close, it is the applicants'
responsibility to advice Regions Billing service, Inc.
immediately.
|
Date
|
By
|
Title/Position
|
|
The undersigned (whether on or more, the "Guarantor") individually, jointly, severally, absolutely, independently, and unconditionally guarantees the prompt payment when due of all amounts owed by the applicant named above to Regions Interstate Billing Service, Inc. including reasonable attorney's fees. This guaranty applies to any and all
debts owed to Regions IBS.
|
Name
|
|
Name
|
Social Security #
|
|
Social Security #
|
Date
|
|
Date
|
| |
|