Bergstrom Automotive Business Credit Application

Bergstrom Automotive Business Credit Application

Complete this application in full to request business credit with Bergstrom Automotive. All sections must be filled accurately. Online submission is supported.
Company Information
Name of Company*
Address
Mailing Address (If different than street address)
Accounts Payable Contact*
Accounts Payable Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address for Monthly Statement*
example@example.com
How would you prefer to receive Monthly Statements?*
Amount of Credit Desired ($)*
Is a Purchase Order Required?*
Appleton AcuraAppleton ChevyAppleton LexusAppleton Victory Lane ImportsAppleton Premier MotorcarsAppleton KiaAppleton BuickAppleton GenesisSouth German Imports (Porsche Audi)Enterprise MotorcarsNeenah ChevyNeenah FordGreen Bay ChevroletGreen Bay FordGreen Bay MazdaGreen Bay CadillacGreen Bay SubaruGreen Bay HyundaiGreen Bay VolkswagenManitowoc GMKaukauna ChryslerOshkosh ChryslerOshkosh ChevyOshkosh Honda NissanOshkosh SubaruOshkosh KiaOshkosh VolkswagenOshkosh FordOshkosh ToyotaMiddleton ChevyMadison CadillacMadison ChevyMadison Lexus
Person(s) authorized to Use Account
Business Type*
Social Security Number (If individual or partnership)
Federal Tax ID Number (If Corporation)
Years in Business
Sales Tax Exempt
Ownership
Principal 1 Name
Principal 1 Address
Principal 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Principal 2 Name
Principal 2 Address
Principal 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Bank Reference
Bank Name
Bank Account Number
Bank Contact Name
Bank Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Bank Contact Email Address
example@example.com
Business References

Please list five business references. *NOTE: Include Email Address expedite credit requests*
Business Reference 1 Name
Business Reference 1 Phone/Fax
Business Reference 1 Address
Business Reference 1 Email
example@example.com
Business Reference 2 Name
Business Reference 2 Phone/Fax
Business Reference 2 Address
Business Reference 2 Email
example@example.com
Business Reference 3 Name
Business Reference 3 Phone/Fax
Business Reference 3 Address
Business Reference 3 Email
example@example.com
Business Reference 4 Name
Business Reference 4 Phone/Fax
Business Reference 4 Address
Business Reference 4 Email
example@example.com
Business Reference 5 Name
Business Reference 5 Phone/Fax
Business Reference 5 Address
Business Reference 5 Email
example@example.com
Applicant Authorization
I/We hereby authorize a credit inquiry as found necessary to investigate my/our income, liabilities, credit history and financial responsibilities. I/We hereby consent the release and disclosure of the above information sought by those inquiries. By signature of this application, I/We understand and agree to comply with the payment terms: 10th of the month following date of service or purchase.
Signature*

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Date*

MonthDayYear
Date
Printed Name*
Title*
Individual Personal Guaranty
Guarantor Name
Guarantor Home Address
Company Name (Guaranty)
Title (Guaranty)
Guaranty Acknowledgement
I, {q62_textbox60} residing at{q66_textbox64}, for and in consideration of extending credit at my request to {q67_textbox65}, (hereinafter referred to as “Company”), of which I am {q68_textbox66}, hereby personally guarantee to you the payment at Bergstrom Automotive in the State of Wisconsin of any obligation of the Company and I hereby agree to bind myself to pay you on demand any sum, which may become due to you by the Company whenever the Company shall fail to pay the same. It is understood that this guaranty shall be a continuing and irrevocable guaranty and indemnity for such indebtedness of the Company. I do hereby waive notice of default, non-payment and notice thereof and consent to any modification or renewal of the credit agreement hereby guaranteed.
Guarantor Signature

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Date (Guaranty)

MonthDayYear
Date
Guarantor Printed Name
Should be Empty:

Bergstrom Automotive Business Credit Application

Company Information

Ownership

Bank Reference

Business References

Applicant Authorization

Individual Personal Guaranty