BusinessIQ

Credit Information

^*Credit Limit Requested
$

^*Previous customer?
Yes No

Date

Account Number

Cash Account

Tax Customer

Previous Account Name/Account #

^*Who Are You Requesting Credit With?

^*What Town/City Shopping From?

^*Preferred Communication Method?

^*Preferred Invoicing Method?

^*Preferred Statement Method?

Company Information

^*Business/Customer Name

Doing Business As (DBA Name)

^*Billing Address

^*City

^*State/ Province

^*Zip/Postal

Country

Shipping Address

City

State/ Province

Zip/Postal

Country

^*Telephone - Work

Telephone - Cell

Fax Number

^*Email Address

Legal Structure

^*Are you Tax Exempt?
Yes No

^*Application Contact Name

Telephone - Work

Application Contact Email Address

Mailing Address

Mailing Address2

City

State/ Province

Zip/Postal

Do You Require A Purchase Order?
Yes No

^*Business Type

If Corporation Yes Complete Next Fields

1 President Name

1 President Address

1 President Social Security No

2 Vice President Name

2 Vice President Address

2 Vice President Social Security No

3 Treasurer Name

3 Treasurer Address

3 Treasurer Social Security No

4 Secretary Name

4 Secretary Address

4 Secretary Social Security No

If Partnership Yes Complete Next Fields

1 Partner/Owner Name

1 Partner/Owner Home Address NO PO Box

1 Partner/Owner City, State, Zip Code

1 Partner/Owner Social Security No

1 Partner/Owner Spouse's Name

If Sole Prop Yes Complete Next Fields

2 Partner/Owner Name

2 Partner/Owner Home Address NO PO Box

2 Partner/Owner City, State, Zip Code

2 Partner/Owner Social Security No

2 Partner/Owner Spouse's Name

If LLC Yes Complete Next Fields

3 Partner/Owner Name

3 Partner/Owner Home Address NO PO Box

3 Partner/Owner City, State, Zip Code

3 Partner/Owner Social Security No

3 Partner/Owner Spouse's Name

Trade Reference Information

Reference Name

Reference Type

Reference Account Number

Reference Account Type

Reference Account Balance
$

Phone Number

Fax Number

Reference Email

Contact Name

Phone Number

Contact Email

Reference Name

Reference Type

Reference Account Number

Reference Account Type

Reference Account Balance
$

Phone Number

Fax Number

Reference Email

Contact Name

Phone Number

Contact Email

Principal Guarantor Information

Principal Type

Principal First Name

Principal Middle Name

Principal Last Name

Principal Home Address

City

State/ Province

Zip/Postal

Telephone - Home

Telephone - Work

Principal Email Address

Principal Social Security Number (SSN)

Personal Guarantee Authorization (Y/N)
Yes No

Personal Guarantee

Signature Of Guarantor

Title

Date

To induce Automotive Parts Headquarters, Inc. to extend credit to the above Applicant, the undersigned hereby guarantees payment, when due, of all amounts, including Service Charges, payable by Applicant to Automotive Parts Headquarters, Inc. Any revocation of charge privileges shall not affect the guaranty with respect to amounts owed before receipt of the Notice of Revocation. Notices of acceptance, default and non-payment are hereby waived. This Guaranty shall be a continuing and irrevocable guaranty and indemnity for such indebtedness of the Applicant's business. I/WE do consent to any modification, extension and/or renewal of the credit agreement hereby guaranteed. If the Applicant fails to pay the account when due, Automotive Parts Headquarters, Inc. may proceed hereunder without notice to exercise the legal remedies available to enforce collection of the balance due, and the Applicant/Guarantor shall be responsible for all costs of said collection, including reasonable attorney fees.

Credit Information

Company Information

Trade Reference Information

Principal Guarantor Information

Personal Guarantee

Attachments

Terms and Conditions

User Verification