Credit Application for Business Account

Credit Application for Business Account
What type of account would you like to obtain?
Business Information
Company Name
DBA (if different)
Phone Number
Format: (000) 000-0000.
Mobile Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Email
example@example.com
Billing Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Shipping Address
Shipping Information

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Company
Estimated Monthly Purchase Volume
Date Business Established

MonthDayYear
Date
# of Employees
Federal Tax ID# (EIN) or SSN
Sales Tax ID#
Sales Tax Exempt?
Upload Pennsylvania Tax Exempt Certificate (REV-1220)

Cancelof

Business and Credit Info
Accounts Payable Contact

First NameLast Name
Accounts Payable Phone
Format: (000) 000-0000.
Accounts Payable Fax
Format: (000) 000-0000.
A/P E-mail
example@example.com
Owner's Name

First NameLast Name
Owner's SSN or EIN
Owner's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Owner's Email
example@example.com
Owner's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bank Name
Bank Phone Number
Format: (000) 000-0000.
Bank Contact

First NameLast Name
Email
example@example.com

Business References
Reference 1: Company Name
E-mail
example@example.com
Phone Number
Format: (000) 000-0000.
Fax Number
Format: (000) 000-0000.
Reference 2: Company Name
E-mail 2
example@example.com
Phone Number 2
Format: (000) 000-0000.
Fax Number 2
Format: (000) 000-0000.

Agreement
Business Agreement

By signing below, I certify that I have the authority to bind the company to this agreement, and that I agree to creditor’s terms of sale of NET 30 for charge accounts and pre-payment/upon delivery for COD, I also agree and accept that the credit limit and credit terms maybe changed or withdrawn at the sole discretion of the creditor. Creditor shall include creditor subsidiaries, related companies, and assigns.

The information given herein is offered as part of a request by the applicant for an extension of credit for commercial business use. The information provided is represented by the applicant to be true, correct and complete. The Applicant authorizes Creditor to investigate all credit references and other sources pertaining to our credit and financial responsibility. The undersigned authorizes its banks and trade creditors to provide Creditor with complete information for the purpose of credit evaluation. The applicant understands that all past due balances will be subject to a 1 ½% per month finance charge. The applicant further agrees to pay all collection fees in the event of default, if the account is placed with a collection agency or attorney.
Print Name
Applicant's Title
Signature
Date

MonthDayYear
Date
PERSONAL GUARANTEE

I, the undersigned, hereby agree to be personally liable for all amounts owed to Chuck’s Auto Parts Solutions (“the Company”) by the business applicant. By signing below, I acknowledge and agree that this Personal Guarantee is an absolute, continuing, and unconditional guarantee of payment. If the business applicant fails to pay any balance when due, I understand that I am personally responsible for the full amount owed, including any collection costs, legal fees, and interest permitted by law.

I further affirm that I am authorized to execute this guarantee and that I am signing it willingly, with full understanding of the obligations and liabilities it creates.
Print Name
Applicant's Title
Signature
Date

MonthDayYear
Date
Should be Empty:

Credit Application for Business Account

Business Information

Business and Credit Info

Business References

Agreement

Business Agreement

PERSONAL GUARANTEE