Parts Services International - Credit Application

251 Union Street Westfield, MA 01085
1-800-628-9034

Credit Application

*First Name
*Last Name
*Company
*Billing Address
*City
*State
*Zip
Country
*Phone
Fax
*Email
Shipping Address
City
State
Zip
Country
Credit Information:
Estimate of credit requested:
Type of business:
D & B Rating
Tax ID or SS#:
Years in Business:
Credit References:
Bank Reference Name:
Account #:
Phone:
Contact:
Trade Reference Name:
Account #:
Phone:
Contact:
Trade Reference 2 Name:
Account #:
Phone:
Contact:
Trade Reference 3 Name:
Account #:
Phone:
Contact:
Is applicant subject to sales tax?
Tax Exemption Number:
Please advise if Parent, Division, Branch or Subsidiary:
This section to be completed by Proprietorship or Partnerships. Name of owner or authorized persons who will be responsible for payment of account. (Minimum of two references.)
Name:
Address:
Phone:
SS#:
Bank (Personal):
Position or Title:
Name:
Address:
Phone:
SS#:
Bank (Personal):
Position or Title:
By submitting this form the applicant acknowledges that should credit be approved, the terms are net 30, from the date of invoice. Invoices not paid within these terms may be subject to a service charge.