Credit Application for Business Account Form

Credit Application for Business Account Form

Business Contact Info

Credit Application for Business Account
Company Name*
Phone Number*

Area CodePhone Number
Capricorn Account Number (if a member)

Capricorn Account NumberRegion
E-mail*
Company Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sole ProprietorshipPartnershipCorporationOther

Business and Credit Info
Accounts Payable Contact*

First NameLast Name
Accounts Payable Phone*

Area CodePhone Number
E-mail*
Company to Bill Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Name*
Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Bank Phone Number*

Area CodePhone Number

Business References (Please DO NOT include BNT, REPCO/NAPA as references):
Reference 1: Company Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Fax Number

Area CodePhone Number
E-mail
Type of Account
Reference 2: Company Name
Address 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number 2

Area CodePhone Number
Fax Number 2

Area CodePhone Number
Type of Account 2
Reference 3: Company Name
Address 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number 3

Area CodePhone Number
Fax Number 3

Area CodePhone Number
Type of Account 3

Agreement

(By checking these boxes you are agreeing to our terms - should you have any questions please contact us)
Excluding the opening buy special. All invoices are to be paid on or prior 20th of the month following from the date of the invoice.
Claims arising from invoices must be made within 7 business days of the invoice date. Item(s) must be returned to us. Procured parts are non-refundable.
By submitting this credit application, you authorize us to make inquires into the banking and buisness references that you provided.
Enter the word as it's shown*
Signature

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