Collins Distribution Retailer Application Parts Retailer Application 2019

INSTRUCTIONS Online via desktop or laptop 1) Open the Application in your web browser. 2) Select the DOWNLOAD PDF button ( ) from the left sidebar. 3) Once downloaded to your desktop or laptop, select any field to type in your answers. (This feature requires Adobe Acrobat Reader. If you don’t have it, go to https://get.adobe.com/reader to install the free Acrobat Reader.) We recommend you save the PDF Application frequently so as not to lose your work. (To save select FILE > SAVE AS. Rename the file with your company name.) PARTS RETAILER APPLICATION 4) Once all fields are completed, attach the saved PDF file to an email and send to ncd@collinsdistribution.com 5) You will be notified once your application has been approved. If you prefer not to complete the Application online Print, complete and mail the Application to our New Customer Development department. COMPANY INFO Business Name: __________________________________________________________________________________________________ OE#: __________________ Address (city, state, zip): ___________________________________________________________________________________________________________________ Phone: ___________________________ Fax: ___________________________ Email: ________________________________________________________________ SHIPPING ADDRESS (if different from above): Address (city, state, zip): ___________________________________________________________________________________________________________________ Federal Tax ID#: __________________________________________ State Sales Tax ID#: __________________________________________ Yrs. in Business: _____ Type of Ownership: Sole___ Partnership___ Corporation___ Other___ Owner’s Name #1: ______________________________________________ Title: ____________________________ SS#: ____________________ Ownership %: _____ Owner’s Name #1: ______________________________________________ Title: ____________________________ SS#: ____________________ Ownership %: _____ BANK REFERENCES CHECKING: Bank Name: _________________________________ Acct No.: ________________________ Contact Name & Phone No.: ____________________________________ Address (city, state, zip): ___________________________________________________________________________________________________________________ SAVINGS: Bank Name: _________________________________ Acct No.: ________________________ Contact Name & Phone No.: ____________________________________ Address (city, state, zip): ___________________________________________________________________________________________________________________ LOAN/OTHER: Bank Name: _________________________________ Acct No.: ________________________ Contact Name & Phone No.: ____________________________________ Address (city, state, zip): ___________________________________________________________________________________________________________________ TRADE REFERENCES PREFERRED PAYMENT METHOD: Business Credit Card___ Net 15___ Net 30___ COD___ (Note: Net 15, Net 30 & COD requires credit check at bank and meeting certain other criteria. Additional shipping charges apply to COD.) Bank Name #1: _________________________________ Acct No.: ________________________ Contact Name & Phone No.: __________________________________ Address (city, state, zip): ___________________________________________________________________________________________________________________ Bank Name #2: _________________________________ Acct No.: ________________________ Contact Name & Phone No.: __________________________________ Address (city, state, zip): ___________________________________________________________________________________________________________________ SIGNATURE Signature: ___________________________________________________________________________ Date: ______________________________________________ Printed Name: ________________________________________________________________________ Title: _______________________________________________ PERSONAL GUARANTY OF OBLIGATIONS In consideration of your extension of credit to the above-named applicant (hereinafter referred to as “Company”), the undersigned, having a financial interest in the Company, (thereinafter “Guarantors”) hereby jointly and severally guarantee the payment of all of the Company’s present and future indebtedness to Collins Distribution, regardless of whether Company is presently indebted to Collins Distribution. If Company fails to pay any amount within 30 days after it becomes due, the undersigned jointly and severally agree to pay such amount on demand, together with reasonable attorney’s fees and costs incurred in collection of the delinquent balance. This is a continuing guarantee and is irrevocable. This instrument is intended to cover all of Company’s present and future indebtedness or liability, and all extension or renewals thereof. In the event of any legal action involving any such indebtedness or liability, the parties agree that venue shall be in Grant County, Indiana. With respect to all disputes relating to obligations of the Company, Company and Guarantors submit themselves to the personal jurisdiction of the state courts of appropriate subject matter jurisdiction in Grant County, Indiana. Guarantor Signature: __________________________________________ Printed Name: __________________________________________ Date: ________________ Witness Signature: ____________________________________________ Printed Name: __________________________________________ Date: ________________ Collins Distribution . 1139 S. Baldwin Avenue, Marion, IN 46953 . (800) 825-1100 ext 1138 . fax (765) 662-9959 . ncd@collinsdistribution.com