CREDIT APPLICATION

To apply for credit, please fill out the form below and press submit to send it to us. If you would rather print out the form and fax/email it, please click here. Email (info@autotech-inc.com) or fax (704.784.8105).

COMPANY PROFILE:

Company Name

Taxpayer ID #

Billing Address

*Resale Number

City, State, Zip

Year Established

Shipping Address

   

City, State, Zip

   

Phone Number

Fax Number

E-mail

 

Fax # (AP Dept)

COMPANY OWNERSHIP:

Ownership:   Proprietorship    Partnership     Incorporated State Year

Officers/Owners:

Name

Phone Number

SSN

 

 

Name

Phone Number

SSN

 

 

Controller

Accounts Payable Contact

NOTE: OUR STANDARD PAYMENT TERMS ARE NET 15 DAYS FROM DATE OF INVOICE. IF YOUR COMPANY DESIRES OTHER TERMS, PLEASE CALL THE OFFICE AND SPEAK TO ACCOUNTS RECEIVABLE ABOUT THIS.

I have read and accept the terms & conditions

Electronic Signature

Title

Date

REFERENCES
 Trade References: (Industry References Preferred)

Reference 1 Name

Reference 2 Name

Address

Address

City, State, Zip

City, State, Zip

Phone

Phone

Fax

Fax

Reference 3 Name

   

Address

   

City, State, Zip

   

Phone

   

Fax

   

BANK REFERENCE

Name

Phone

Address

Account #

City, State, Zip