Dr. Trailer Repair Inc. 

Buffalo, New York

 

WE PROVIDE REPAIR WORK FOR COMMERCIAL TRUCKS, DIESEL, TRAILER AND TRACTOR TRAILERS. 

716-605-6409

470 Fillmore Ave Tonawanda, NY 14150

 

 

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ON LINE CREDIT APPLICATION

  Name

  Company Name

  Address

  City      State    Zip

  Phone     Fax    Email

Business Is    PO Required      Credit Limit Requested


Name of Principal(s) of Business

Owners Name  

Title

Address

 Owners Name  

Title

Address

Person authorized to make purchases

Are you tax exempt?   Tax Number


TRADE REFERENCES

 Name                                     

Address                 

City               State       Zip       

Phone / Fax


Name         

Address            

City                   State        Zip    

Phone / Fax 


Name              

Address             

City                  State        Zip    


BANK REFERENCES

Bank Name            City    State             

Account Number     Bank Phone number 


Bank Name            City    State 

Account Number     Bank Phone Number 

 

Questions / Comments           

I agree to attest the financial responsibility, ability and willingness to pay our invoices in accordance with the terms and authorize investigation of all statements contained in this application concerning credit histories. I understand the payment terms are specified by an invoice service charge of 1% per month on all overdue balances (balances will include any prior unpaid service charges). I understand overdue accounts may be referred to an attorney for collection and if suit is commenced, I agree to pay reasonable attorney's fees.

I also hereby certify that I am authorized to submit this form and that the information is true and correct. I further understand that a typed version of my name is being accepted as my original signature pursuant to the Federal Electronic Signature Act.   

Name   

  Title        Date

 

 

       (will clear complete form)