This application must be completed in full and signed by a principal office 

                                         or owner of your company. Payment can only be accepted by credit card at this time.

Credit Card Type:_________________________    #:_______________________________________
Name or Business Listed on Card_____________________Exp______________CVV2 code_____*

Billing Address for Card _______________________City _____________ State______ Zip_______

Authorized Signature________________________________________________________________
(* last 3 digits on back of card)

Company Information

Type of Business ____________ # of Employees ________Expected Monthly Purchases ________

Name of Company __________________________________ Phone (       )  ___________________

Mailing Address____________________ City ___________________ State ______ Zip __________

Shipping Address ___________________City __________________ State ______ Zip ____________

Business Phone (        )_____________ Fax (         )_______________________

Accounts Payable Manager____________________ Phone (         )_______________ Ext. _________

E-mail Address ___________________ Would you like to receive e-mail specials:     q Yes  q No     

Website: _______________________________

Business History

qSole Proprietorship   qPartnership    qCorporation    qDivision*     qSubsidiary*     qFranchise*

* Division/Subsidiary/Franch______________________________ Phone (       ) __________________

Date Business Established ____________ Federal ID #______________________________

Principal Owner or Stockholder

Name_______________________________________ Title _____________
 
Social Security #_____________ Home Phone (     ) _______________________________________

Residence Address___________________________________________________________________
Has Business Changed Ownership in the last twelve months?  qYes  qNo If yes, when? _________  

Trade Reference   (Please list other warehouse distributors or major suppliers.)

1) Name ____________________________________________  FAX (         ) _______________

2) Name ____________________________________________ FAX (          ) ________________

3) Name ____________________________________________ FAX (          ) ________________

4) Name ____________________________________________  FAX (         ) _________________

5) Name ____________________________________________   FAX (         ) ________________

Bank Reference

Name of Bank _________________________________________ Phone (         ) _____________

Address _________________City _____________State _______Zip _______Account __________
 
Accounts Receivable & Inventory Secured for Loans:   q  Yes  q No
Any other liens, taxes, judgements, or lawsuits pending?  q Yes  q No  

I/we authorize Weathers Auto Supply to investigate the bank/trade references listed for the purpose of obtaining an account. I hereby declare that all statements in this application are true.  
Your signature below also indicates you have read and agree to our Terms and Policies

  Signature______________________________________ Date ____________________________

  Print Signature____________________________________________________________________

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