A1 American Credit Application Date Date Format: MM slash DD slash YYYY Company Legal Name:*Doing Business As:*Phone:*Ext:Fax:Billing Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Shipping Address: Same as Above Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent Company Name:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Affiliated Companies:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Check One: PROPRIETORSHIP CORPORATION PARTNERSHIP OTHER If OTHER, please specify:Desired Credit Limit:*Business Start Date: Date Format: MM slash DD slash YYYY State of Registration:Federal Tax ID No:Type of Business:Sales Tax Exempt?YesNoIf Yes, please attach valid Sales Tax CertificateDo You Require a Purchase Order?YesNoCOMPANY CONTACT INFORMATIONPrimary Company Contact:Phone:Ext:Fax:Email: Accounts Payable Contact:Phone:Ext:Fax:Email: CORPORATE OFFICERS, MEMBERS, PARTNERSHIP OR PROPRIETORSHIP INFORMATIONPrincipal’s Name:Title:Principal’s Name:Title:Principal’s Name:Title:Principal’s Name:Title:BANK REFERENCE INFORMATIONBank Name:Contact Name:Phone:Ext:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Checking Account #:Saving Account #:COMPARABLE VENDOR REFERENCE INFORMATIONVendor Name:Account #:Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Ext:Fax:Vendor Name:Account #:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Ext:Fax:Vendor Name:Account #:Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Ext:Fax:W-9 FormDOWNLOAD W-9 FORM HERE *PLEASE NOTE: You must download, complete, sign, and upload the W-9 document with this credit application. Any application without a W-9 form will not be processed.W-9 File Upload*TO BE READ AND COMPLETED BY ALL APPLICANTSHas the Applicant filed for bankruptcy, or been the subject of an involuntary bankruptcy petition, in the past 10 years? Yes No Have any unsatisfied judgment(s) been entered against Applicant in the past 7 years? Yes No Have any tax lien(s) been filed against the Applicant in the past 7 years? Yes No If the answer to any one or more of the foregoing questions is “yes”, please attach an explanatory statement. APPLICANT CERTIFICATION. By signing below, (a) I, on behalf of my business (the “Applicant”), hereby request credit from the company(ies) selected above (each, a “Creditor”) for the purpose of financing the Applicant’s purchase of goods from Creditor; (b) I authorize Creditor to investigate the Applicant’s creditworthiness, including without limitation by obtaining credit reports and other information, and to share such information with any Creditor or affiliate of a Creditor or any third party in connection with this application or any credit extended by Creditor to Applicant; (c) I authorize all of Applicant’s past and present banks, lenders, lessors, landlords, trade creditors and other creditors to provide Creditor or its designee with any and all information that will assist Creditor in its credit inquiry; and (d) I certify that all information provided in this application about the Applicant and myself is accurate and complete. This application is given for the purpose of obtaining credit. Applicant agrees that, if credit is extended in response to this application, the terms and conditions applicable to such credit shall be as set forth in between Applicant and Creditor(s), and may be amended from time to time. OFFICER/PARTNER CERTIFICATION. By signing below, (a) I certify that I am authorized on behalf of the Applicant to apply for credit for the Applicant, and (b) I authorize Creditor to verify credit and other information about me relevant to this application, and to obtain consumer report(s) about me from consumer reporting agencies. GUARANTOR AUTHORIZATION. By signing below, (a) I certify that all of the information about me provided in this application is accurate and complete, and (b) I authorize Creditor to verify credit and other information about me relevant to this application, and to obtain consumer report(s) about me from consumer reporting agencies. IMPORTANT LEGAL NOTICES The term “me” in these Notices refers to an officer or guarantor of Applicant, who has signed this application, or to the Applicant if Applicant is a sole proprietor who has signed this application, or to a partner in Applicant who has signed this application if Applicant is a partnership.Company NameSTATEMENT OF TERMS Seller establishes, in the name of the applicant, subject to approval, an open account for the purchases of goods from Seller in accordance with the terms and conditions listed below. The terms set forth herein shall apply to sales from any A1 American, and shall continue until the undersigned cancels this agreement in writing. The Undersigned authorizes any bank, credit reporting agency, or credit references to release Undersigned’s individual and/or company credit information to Seller. Seller may check credit references as often as it deems necessary. The Undersigned expressly agrees to pay interest/finance charges on any past due amounts at the rate of 1.5% per month. The Undersigned further agrees to pay all reasonable collection costs and/or court costs and/or attorney fees incurred in connection with the collection of this account. Merchandise returned is subject to a 15% restocking fee, and all merchandise tendered for return is subject to inspection. No credit will be allowed for damaged, mutilated, altered, obsolete, or otherwise unsaleable merchandise.Print Name:* First Last Signature*(OFFICER/PARTNER/MEMBER/SOLE PROPRIETOR) ELECTRONIC SIGNATURE AGREEMENT - by signing this credit application agreement, you will be entering into an electronic agreement, evidenced by an electronic record. You will also be consenting to the use of an electronic signature to manifest your agreement to the terms and conditions in the credit application terms. This consent is limited to that particular transaction and does not apply to any future transactions entered into by you and A1 American. You must electronically acknowledge that you have read these disclosures and agree to all terms.Date* Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
