Independent Ag Equipment

APPLICATION FOR ACCOUNT PLEASE GIVE COMPLETE ANSWERS TO ALL QUESTIONS: (PLEASE PRINT OR TYPE) NOTE: THIS APPLICATION WILL BE RETURNED IF NOT COMPLETED IN FULL.

Complete Business Name: ____________________________________________________________________________________________

(If incorporated, print exactly as shown on Corporate Charter)

Type of Business: ____________________________________________________________________________________________________ Number of Years in Business: ________________ Phone (Bus): ( )______________________ Fax #: ( ) ____________________ Street Address or Physical Location:______________________________________________________________________________________ Billing Address: ______________________________________________________________________________________________________ Purchasing Agent: ______________________________________________ E-mail address: ______________________________________ Annual Sales: ________________________________________ Type of Organization: Corporation Federal Tax I.D. Number: ______________________________________________________________________ Partnership Federal Tax I.D. Number: ______________________________________________________________________ Individual List of Complete Names of All Principals: ________________________ ________________________ ________________________________________ ______________________ ________________________ ________________________ ________________________________________ ______________________ ________________________ ________________________ ________________________________________ ______________________ Credit References: Banks (include personal bank if proprietorship or partnership): Name Title Home Address Social Security Number

ACCOUNT APPLICATION

ACCOUNT APPLICATION

1. ______________________ _________________________________________ _______________________ (

) ________________

Name

Complete Address

Officer to Contact

Telephone Number

2. ______________________ _________________________________________ _______________________ (

) ________________

Equipment dealers and other suppliers that have extended credit to you ( must include fax number or email) :

3. ______________________ __________________________________________________________________________________________ ( ) ______________________ ( ) _________________________ _________________________________________________ 4. ______________________ __________________________________________________________________________________________ ( ) ______________________ ( ) _________________________ _________________________________________________ 5. ______________________ __________________________________________________________________________________________ ( ) ______________________ ( ) _________________________ _________________________________________________ 6. ______________________ __________________________________________________________________________________________ ( ) ______________________ ( ) _________________________ _________________________________________________ Name of Suppliers or Finance Co. Complete Address Name of Suppliers or Finance Co. Complete Address Name of Suppliers or Finance Co. Complete Address Name of Suppliers or Finance Co. Complete Address Telephone Number Fax Number Required Email Required Telephone Fax Number Required Email Required Telephone Fax Number Required Email Required

Telephone

Fax Number Required

Email Required

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250 | INDEPENDENT AG EQUIPMENT PRODUCT CATALOG | PA: 800-345-3546 | OH: 800-848-8460 | IN: 888-563-1988 | www.IndependentAg.com