2017 Equipment & Parts Catalog
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: _________________________________________
ACCOUNT APPLICATION Type of Organization:
R Corporation
Federal Tax I.D. Number: ______________________________________________________________________
R Partnership
Federal Tax I.D. Number: ______________________________________________________________________
R Individual
List of Complete Names of All Principals:
________________________ _______________________ _______________________________________ _____________________
Name
Title
Home Address
Social Security Number
________________________ _______________________ _______________________________________ _____________________
________________________ _______________________ _______________________________________ _____________________
Credit References: Banks (include personal bank if proprietorship or partnership):
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. ______________________ _________________________________________________________________________________________
Name of Suppliers or Finance Co.
Complete Address
(
) _____________________ (
) ________________________ ________________________________________________
Telephone Number
Fax Number Required
Email Required
4. ______________________ _________________________________________________________________________________________
Name of Suppliers or Finance Co.
Complete Address
(
) _____________________ (
) ________________________ ________________________________________________
Telephone
Fax Number Required
Email Required
5. ______________________ _________________________________________________________________________________________
Name of Suppliers or Finance Co.
Complete Address
(
) _____________________ (
) ________________________ ________________________________________________
Telephone
Fax Number Required
Email Required
6. ______________________ _________________________________________________________________________________________
Name of Suppliers or Finance Co.
Complete Address
(
) _____________________ (
) ________________________ ________________________________________________
Telephone
Fax Number Required
Email Required
Continued on next page
250 | INDEPENDENT AG EQUIPMENT PRODUCT CATALO G | PA: 800-345-3546 | OH & IN: 800-848-8460 | www.IndependentAg.com
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