2305 County Road 3210 Mount Pleasant, TX 75455
Distributor Application
Business Name
*
Phone Number
*
Date
*
/
Month
/
Day
Year
Website
Physical Street Address
*
City
*
State
*
Zip
*
Billing Address (Select “Yes” if same as Physical Address above)
YES
Billing Street Address
City
State
Zip
Point Of Contact
Point Of Contact Phone Number
Point Of Contact Email
example@example.com
Accounts Payable Point Of Contact
Accounts Payable Phone Number
Please enter a valid phone number.
Accounts Payable Email
example@example.com
Federal Tax ID
State Tax ID
Years In Business
Number Of Locations
Total Annual Sales Revenue
Expected Annual NXG Purchases
Number Of Employees
Company Type
Brands Carried
Ownership Information
Name
*
First Name
Last Name
Street Address
City
State
Zip
Phone Number
Please enter a valid phone number.
Email
example@example.com
Banking Information
Bank
*
Name
*
Contact First Name
Contact Last Name
Address
City
State
Zip
Phone Number
Please enter a valid phone number.
Account Number
Routing Number
Floorplan Information
Northpoint Floorplan
*
Yes
No
Red Oak Finance
*
Yes
No
Floorplan Account Number
Limit
References Information
Reference 1
Company Name
Phone
Account Number
Email
example@example.com
Contact Name
Contact First Name
Contact Last Name
Products Purchased
City
State
Reference 2
Company Name
Phone
Account Number
Email
example@example.com
Contact Name
Contact First Name
Contact Last Name
Products Purchased
City
State
Reference 3
Optional
Company Name
Phone
Account #
Email
example@example.com
Name
Contact First Name
Contact Last Name
Products Purchased
City
State
In the event that NXG Truck Bodies must incur collection costs or initiate legal action to recover any amount due under this agreement, in whole or in part, the undersigned agrees to pay all additional collection costs, charges, and expenses, including reasonable attorney's fees incurred by NXG Truck Bodies. All invoices are due as noted on the invoice. Late fees will be assessed monthly for past due balances at a rate of 1.5% monthly 18% annually The undersigned further agrees that the purchase shall be subject to NXG Truck Bodies' standard Terms and Conditions, which are available for review on the NXG Truck Bodies website. Additionally, as more fully outlined in the Terms and Conditions and in accordance with the Uniform Commercial Code, the undersigned grants NXG Truck Bodies a first-priority purchase money security interest in the goods, which remains in effect until NXG Truck Bodies has been paid in full for each item purchased.
Signed
*
Date
*
-
Month
-
Day
Year
Date
Reference Sheet Attached
YES
Copy of your W-9 and Tax Exemption Certificate attached.
*
YES
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