Credit Application                        

I. CONTACT INFORMATION

Name
Title
Organization
Billing Address
Address (cont.)
City
State/Province
Zip/Postal Code
Shipping Address
Address (cont.)
City
State/Province
Zip/Postal Code
County
Work Phone	Ext.
Home Phone
Fax
E-mail
Web Address

II. PRINCIPAL OF BUSINESS

• Proprietorship: List Name, Home Address, Social Security Number

• Partnership:      List Name, Home Address, Social Security Number

• Corporation:    List Officers, Titles, Federal ID Number:           

III. REFERENCES

List complete name, full address of creditors including zip codes.

Bank Reference:

IV. ACCOUNT INFORMATION

1. List the number of years in business................................................... 1 2 3 4 5 6 7 8 9 10 10+

2. Do you require Purchase Order Numbers on your billing...................Yes   No

3. Will you accept backorders if we do not have the part in stock.,........Yes   No

4. Do you have a Sales Tax Number ....................................................Yes   No

            (If yes, please write it here)

             Note----Please Complete Sales Tax Form. (Resale Tax Form) (Download PDF)

Most orders are shipped via UPS or FED EX Ground. Your shipment must be classified as either Residential or Commercial. "A residential delivery is one made to a home, which includes a business operated out of a home." Please indicate your delivery status below: Residential Commercial .   Delivery Method: UPS FED EX .

Please indicate lines carried or interested in:

    Amana     Dacor     Frigidaire     GE     Maytag     Speed Queen     Whirlpool

V. TERMS OF SALE

All orders are subject to approval by our Home Office. Our terms of sales are NET 10th including warranty and purchases. The purchaser agrees to pay all invoices within terms specified. In the event account becomes delinquent, purchaser agrees to pay collection/attorney fees not exceeding 30%, court costs, and any other miscellaneous expenses incurred as a result of purchaser's failure to pay. A service charge of 1.5% (18% per annum) will be billed on all past due balances.

Signature:______________________________     Title:_____________________________     Date:________________________

Comments:

  Please fax completed and signed form to 1-800-277-2811