CREDIT APPLICATION AND AGREEMENT

CREDIT APPLICATION AND AGREEMENT
To ensure prompt processing, please complete all sections of this application.
OFFICE USE ONLY
Denied
Credit Limit
Terms
Dealer #
CR#1
CR#2
CR#3
Comments
Applicant's Name*
Email*
example@example.com
Mobile Number*
OK to Text*

YesNo
AVX Sales Contact
Dealer #
Requested Credit Amount*
Business Name*
Business Email*
example@example.com
Business Telephone*
Dunn & Bradstreet A*
Address*

Street Address

Street Address Line 2

CityState

Zip
Please Select One*

CorporationPartnershipProprietorship
State*
Year Established*
Personal Guarantee*

YesNo
Principle Name*
Title*
Address *

Street Address

Street Address Line 2

CityState

Zip
SSN*
Principle Name*
Title*
Address*

Street Address

Street Address Line 2

CityState

Zip
SSN*
BANK REFERENCES
Bank*
Checking Acct #*
Savings Acct #*
Loan Acct #*
Contact Name*
Bank Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Phone*
TRADE REFERENCES
Name*
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone*
Account #*
Contact*
Email*
example@example.com
Name*
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone*
Account #*
Contact*
Email*
example@example.com
Name*
Address*

Street Address

Street Address Line 2

CityState

Zip
Phone*
Account #*
Contact*
Email*
example@example.com
For D.W. Collins, Inc., its subsidiaries, divisions, and assignees extending credit to the applicant, the applicant agrees and warrants that the above information on the applicant's behalf are true and complete statements as of the date they bear, and that the credit grantor may rely thereon in processing this application.

The applicant hereby authorizes the credit grantor to verify without liability, the statements contained herein. If credit is extended, the applicant agrees to abide by the AVX Dealer Application Terms and Conditions of credit set forth by the credit grantor. Applicant warrants that should there be substantial change in the financial condition of the applicant, credit grantor shall immediately be so advised.

Applicant agrees to pay all reasonable collection costs, attorney fees and court costs incurred if an overdue account is assigned for collection or if suit is initiated by the credit grantor.

It is further agreed that all overdue accounts shall bear interest at the maximum rate allowed by law. It further agreed that this agreement shall be governed by the laws of the State of Texas.

By signing below, you agree to the information in this credit application and authorize the said Trade References above, to provide credit-related information to D.W. Collins, Inc. dba AVX Wholesale for the purpose of obtaining credit.
Signature*

Clear
Title*
Date*

MonthDayYear
Date
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CREDIT APPLICATION AND AGREEMENT

OFFICE USE ONLY

BANK REFERENCES

TRADE REFERENCES