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General Information
*
Previous customer?
Yes
No
Date
Account Number
Cash Account
Yes
No
Tax Customer
Always Taxed
Never Taxed
Conditional
Previous Account Name/Account #
*
What Town/City Shopping From?
*
Preferred Communication Method?
Email
Phone
Text
*
Preferred Invoicing Method?
At Time of Purchase
Email
Mail
*
Preferred Statement Method?
Email
Mail
*
Who Are You Requesting To Purchase From?
Auto Value Parts Stores
Benco
Refinish Supply Company
Company Information
*
Business Name
Doing Business As (DBA Name)
*
Billing Address
City
State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip/Postal
Country
United States Of America
Canada
*
City
*
State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
*
Zip/Postal
Country
United States Of America
Canada
Shipping Address
City
State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip/Postal
Country
United States Of America
Canada
*
Telephone - Work
Telephone - Cell
Fax Number
*
Email Address
Legal Structure
Not Available
Sole Proprietorship
Limited Liability Company
Cooperative
Corporation
Nonprofit Corporation
S Corporation
Partnership
Limited Partnership
*
Are you Tax Exempt?
Yes
No
*
Application Contact Name
Telephone - Work
Application Contact Email Address
Mailing Address
Mailing Address2
City
State/ Province
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MP
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip/Postal
Do You Require A Purchase Order?
Yes
No
*
Business Type
Body Shop
Auto Repair
New Car Dealer
User Car Dealer
Tire/Undercar Ex. Royal Tire
LD Fleet
Commercial/Manufacturing
Farm/Agricultural
Govt/Municipality/School
Non-Profit
Retail
CSC
Marine/Power Sports/Rec
MD & HD Trucking Fleet
Express Service/Lube Chain
Inactive
Internal Use
Logging
Oil/Mining
Implement Dealer
Other
Attachments
Please attach your sales tax exemption certificate here.
Attachment Description
Attachment Location
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Note: Accepted file formats include PDF, CSV, TXT and various image files (JPEG, JPG, GIF, BMP, TIFF, TIF, PNG, ICO). File attachments must not exceed 10 MB in combined size.
Terms and Conditions
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Signature of Applicant
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Title
*
Date
PRINT AGREEMENT
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I agree to the terms and conditions specified above.
*
User Verification
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