Cipher Auto Wholesale Account Application Form

Wholesale Account Application Form
Company Name
Year Established
Address

Company Address

Street Address Line 2

City, State & Zip CodeState / Province

Postal / Zip Code
Federal Tax ID
Tel:
Fax No.
Email:
example@example.com
Contact Person:
Bank Information Request

Information only required when paying with any company check.
Bank Name
Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone No.
Bank Account No.
I certify that all of the information provided on the application is correct to the best of my knowledge. I understand that the creditor will reply on the application (including the authorization and certification in this paragraph) in deciding whether to grant the request credit and the creditor will keep the application whether or not it is approved. I authorize the creditor to check the credit application and its principles. I certify that (1) I am authorized to bind the applicant to this application and retail installment purchase and other documents I sign In connection with this transaction. (2) I hold the position with the applicant shown below.
Print Name
Signature

Clear
Title
Date

MonthDayYear
Date
CIPHER AUTO, INC.

3710 ROCKWELL AVE, UNIT E, EL MONTE, CA 91731

TEL: 909-542-8868
WWW.ClPHERAUTO.COM
Should be Empty: