application for parts and service account

APPLICATION FOR
PARTS AND SERVICE ACCOUNT
YEARS IN BUSINESS_____ BUSINESS/SERVICE TYPE _____________________________ # OF TRUCKS ______
NAME OF INDIVIDUAL/FIRM: _________________________________________________________________________
STREET ADDRESS: __________________________________________________________________________________
CITY, STATE, ZIP CODE: ______________________________________________________________________________
Please indicate MAILING ADDRESS if different from above: ______________________________________________
_____________________________________________________________________________________________________
APPLICANT IS : INDIVIDUAL_______PROPRIETORSHIP______PARTNERSHIP _______CORPORATION _____
FEDERAL I.D. # _____________________________ SOCIAL SEC. # __________________________________________
OWNERS, PARTNERS OR CORPORATE OFFICERS:
NAME & TITLE ____________________________ ADDRESS:______________________________________________
NAME & TITLE ____________________________ ADDRESS: ______________________________________________
BANK REFERENCES:
NAME____________________________________ ADDRESS: _____________________________________________
CONTACT: ________________________________ ACCOUNT: _____________________________________________
PHONE: __________________________________ FAX: ___________________________________________________
NAME ____________________________________ ADDRESS: ______________________________________________
CONTACT: ________________________________ ACCOUNT: _____________________________________________
PHONE:___________________________________FAX:____________________________________________________
BUSINESS REFERENCES:
NAME_____________________________________ADDRESS:______________________________________________
CONTACT:_________________________________
PHONE:___________________________________FAX:____________________________________________________
NAME_____________________________________ADDRESS:______________________________________________
CONTACT:_________________________________
PHONE:___________________________________FAX:____________________________________________________
NAME_____________________________________ADDRESS:______________________________________________
CONTACT:_________________________________
PHONE:___________________________________FAX:____________________________________________________
Please be sure to include fax numbers. Thank you!
HAVE YOU EVER APPLIED FOR AN ACCOUNT BEFORE: YES___ NO___ (if yes, when?)__________________
UNDER WHAT NAME: _______________________________________
FLORIDA SALES TAX EMEMPT: YES______ NO______ (if yes, please provide copy of certificate)
By signing this application, Applicant grants Nextra Truck Center permission to contact the listed references and
Applicant’s creditors to obtain credit information.
If this application is approved, applicant agrees to pay all purchases by the 10th day of the month following the
month purchase (Due Date). Accounts not paid by the end of the month following the month of purchase may be
placed on COD status. In addition, any such accounts shall bear interest at 1.5% simple interest per month (18%
simple interest per annum) from the Due Date. In the event that collection procedures are required to collect a
delinquent account, Nextran Truck Center will be entitled to recover all costs of application and any agreements
contemplated to be executed with it shall be governed under the laws of the State of Florida.
By: _____________________________________________________
Title: ____________________________________________________
Print Name: _____________________________________ Date: _________________
PAYMENT GUARANTY
To induce Nextran Truck Center to give credit to the Applicant, the undersigned, as an interested party, herby
guarantees the prompt payment when due or upon Nextran Truck Center’s demand for any and all parts,
equipment and/or services rendered to Applicant. This is an absolute, unconditional and continuing guaranty and
can only be revoked in writing and only as to future transactions occurring after the date of revocation.
Signature of Guarantor: _______________________________________
Date: _____________________
Print Name: __________________________________________________
Signature of Guarantor: _______________________________________
Print Name: __________________________________________________
Date: _____________________