Service Application Step 1 of 3 33% Applicant DataLegal Company Name* Federal Tax ID* Business Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*FaxYears in Business*Years at Location*Ownership* Proprietorship Partnership Corporation LLC Ltd Company Website Requested Credit Limit* 1,500 3,000 5,000 Owner Name Main Phone Accounts Payable Contact* Accounts Payable Email* PO Required* Yes No Date* MM slash DD slash YYYY Trade ReferencesPlease list complete addresses and fax numbers for a minimum of 4 trade references with whom you have a credit account. Listing firms that will promptly release information by fax will expedite application processing.Reference Name Guarantors Name Company Name Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFaxBank Name Account Number Bank Name* Account #* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Fax*I hereby declare that the information given on this application is complete and accurate. I understand and agree that the payment terms are NET-30 days (calculated from the invoice date.) I acknowledge that Great Dane Utah Parts & Service, Inc. reserves the right to charge interest at a rate of 1.5% per month or the maximum rate allowed by law on all balances not paid within the above stated terms. I agree to pay, in addition to any delinquent amount and interest charges thereon, collection or attorney's fees equal to 30% of the delinquent balance, or the maximum allowed under state law, whichever is less. By signing, I hereby give my authorization to release any information pertaining to my bank account(s) and/or any trade references to Great Date Utah Parts & Service, Inc.Officer Name* Title* Signature*Date* MM slash DD slash YYYY The undersigned , for consideration do hereby individually and personally guarantee the full and prompt payment of all indebtedness heretofore or hereafter incurred by the above business. This guarantee shall not be affected by the amount of credit extended or any change in the form of said indebtedness. Notice of the acceptance of this guarantee, extension of credit, modification in terms of payment, and any right or demand to proceed against the principal debtor is hereby waived. This guarantee may only be revoked by written notice which shall be sent to the creditor's credit office by certified mail. Any revocation does not revoke the obligation of the guarantors to provide payment for indebtedness incurred prior to the revocation. I authorize the seller and their assigns to obtain a consumer credit report and to contact my references as necessary.Guarantor's Name* First Last Home Address* Street Address City State / Province / Region ZIP / Postal Code Guarantor's Name* First NameHome Address* Street Address City State / Province / Region ZIP / Postal Code The Federal Equal Credit Opportunity Act prohibits credit from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, or age provided the applicant has the capacity to enter into a binding contract because all or part of the applicants income derives from any public assistance program or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal Agency that administer compliance with this law or concerning this creditor is: Federal Trade Commission, Equal Credit Opportunity, Washington, DC.CAPTCHANameThis field is for validation purposes and should be left unchanged.
