Membership Application Form

parts charge account application

Must be signed by company principal/president
Company Information*

Company NameTax ID
In Business Since*
Year
Legal Business Form*
Legal form under which business operates
If Division/Subsidiary, Name of Parent Company*
Company Principal Responsible for Business Transactions*

First NameLast Name
Phone Number of Company Principal*
Please enter a valid phone number.Format: (000) 000-0000.
Email of Company Principal*
example@example.com
Company Local Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Work Number*
Format: (000) 000-0000.
Billing
Accounts Payable Contact*

First NameLast Name
Accounts Payable E-mail*
Use the address above.I want to specify a different billing address.
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Reference
Financial Institution

Name of Financial InstitutionAccount Number
Contact at Financial Institution

First and Last NamePhone Number
Trade Reference
Trade Reference*

Name of BusinessAccount Open Since [Year]
Trade Reference Contact*

First and Last NamePhone Number
Credit Information

Credit LimitCurrent Balance
Terms & Conditions

By signing this form I warrant the information provided herein to be correct and agree to the following:
- To pay all statements of account by the 10th of the month following purchases or otherwise expressly agreed.
- To pay in full any late charges levied for past due accounts.
- In the event of default, to pay collection costs including reasonable attorney's fees and interest at the maximum legal rate.
Personal Guarantor

In the event the company referenced herein becomes unable to repay Murdock Auto Team or any of its dealerships, the undersigned principal or company owner will personally guarantee and repay any outstanding amount due on account.
Date of Signature*

MonthDayYear
Date
Signature of Company Principal/Owner*
Should be Empty:

parts charge account application

Billing

Bank Reference

Trade Reference