MONTHLY CREDIT APPLICATION

MONTHLY CREDIT APPLICATION
APPLICANT INFORMATION
Legal Company Name*
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Please enter a valid phone number.
Cell*
Please enter a valid phone number.
Email*
example@example.com
Manager’s Name
Manager's Phone
Please enter a valid phone number.
Manager's Email
example@example.com
Owner's Name
Owner’s Phone
Please enter a valid phone number.
Owner's Address

Owners' Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Business:*

CorporationProprietorship
Number of Years in Business*
Credit Limit Requested*
G.S.T. Number*
P.O. Number Required?*

YesNo
Accounts Payable Contact: Name
Accounts Payable Contact: Email
example@example.com
Statement Delivery Email*
example@example.com
If “Vehicle Repairs,” please specify:
How many service bays do you have
How many full-time employees do you have
If “Fleet Maintenance,” please specify:
How many vehicles are in your inventory
Please Choose ONE location as your primary contact:*

Auto Value Barlow SE - #155 3953 112 Ave SEAuto Value Country Hills - 170 11358 Barlow Trail NEAuto Value Crowfoot - #4 250 Crowfoot Crescent NWAuto Value Forest Lawn - 5140 Hubalta Road SEAuto Value Macleod Trail - #123 8228 Macleod Trail SEAuto Value Midnapore - 5150 Bannister Road SE)Auto Value 16th Ave - 616 16 Ave NWAuto Value 17th Ave SW - 3821B 17 Ave SWAuto Value 32nd Ave NE - 1633 32 Ave NECentral Auto Parts Distributors (Main Warehouse) - 34 Highfield Circle SEAuto Value Airdrie - #103 1300 Market StreetAuto Value Drumheller - 300 South Railway Ave EAuto Value Lethbridge - 1707 3 Ave SAuto Value Red Deer - 6870 Gaetz Ave
WEEKLY ACCOUNT
Please Supply 3 Business References:
Name of Reference*
Reference #1
Phone*
Please enter a valid phone number.
Email*
example@example.com
Name of Reference*
Reference #2
Phone #*
Please enter a valid phone number.
Email*
example@example.com
Name of Reference*
Reference #3
Phone #*
Please enter a valid phone number.
Email*
example@example.com
Credit Card Information (Optional):

You will receive a call from our accounting department at 403-259-8658 to confirm your card number
Card Number
Expiry Month
Expiry Year
CVC
Name of Card Holder
Monthly Account Terms & Conditions:
- All invoices are due Net 10 (10th day of the month following the statement date).
- Past due balances will incur a 2% monthly fee (24% per year
- Accepted payment methods: cheque, EFT, e-transfer, cash, or credit card.
- Failure to pay the statement balance by the due date will result in the account being placed on stop.
- A $1.00 fee per document applies for each duplicate statement, invoice, credit note, or record of account (ROA) requested.
- Accounts with no activity for 24 months will be closed.
- Any changes to ownership, partnership, or business structure affecting credit arrangements must be reported in writing.
- Central Auto Parts Distributors Ltd. may update these terms at any time, without notice. Continued use of services implies acceptance of updated terms.
I certify that the information provided in this application is accurate and submitted for the purpose of obtaining goods on credit. I authorize Central Auto Parts Distributors Ltd., or its representatives, to contact the listed references regarding my credit history and financial standing. I authorize Central Auto Parts Distributors Ltd., or its representatives, to charge the credit card listed for the weekly outstanding balance on my account.
Signature*

Powered by Jotform SignClear
Name*
Title*
Signing officer of the company
Date*

MonthDayYear
Date
Please verify that you are human*
INTERNAL USE
Account Number
Set-up Date

MonthDayYear
Date
Approved By
Special Pricing
Sales Representative
Credit Limit
Account Approved By
Date Approved

MonthDayYear
Date
Should be Empty:

MONTHLY CREDIT APPLICATION

APPLICANT INFORMATION

WEEKLY ACCOUNT

Please Supply 3 Business References:

Credit Card Information (Optional):

Monthly Account Terms & Conditions:

INTERNAL USE