Parts Service Rental Leasing Application

Company Name

Date

Business Address

Email Address

Do you use Purchase Orders?

Yes

Authorized Purchasers

Business Phone

Business Type

Corporation

Partnership

Individual

Sole Proprietorship

Social Security Number / Tax ID

How long in business?

Credit Limit Requested

Sales Tax must be charted

Yes

State Sales Tax No.

Individual Owner

Name

Residence Address

Residence Phone

Credit References

Minimum of three other than bank or revolving charge card accounts

Name / Contact #1

Phone Number #1

Fax / Email #1

Name / Contact #2

Phone Number #2

Fax / Email #2

Name / Contact #3

Phone Number #3

Fax / Email #3

Name / Contact #4

Phone Number #4

Fax / Email #4

Failure to fill out completely will void application and result in a delay of open account privileges.

I (We) authorize Truck Center Companies to make whatever credit inquiries it deems necessary in connection with this Credit Application or in the course of review or collection of any credit extended in reliance on this application and instruct any person or consumer reporting agency to compile and furnish Truck Center Companies it may have or obtain in response to such credit inquiries and agree that such information, along with this application shall remain Truck Center Companies property whether or not credit is extended. I (We) hereby agree to cooperate in consideration of this privilege by making settlement on or before the Tenth of the Month following purchase. Should payment not be made accordingly, it is understood the amount will be subject to being placed on a CASH BASIS. Accounts not paid within 30 days from the date of sale shall be considered past due and charged interest at a rate of 16% per annum.