Company Name ________________________________________ Phone _____________________

Billing Address ____________________________________________________________________

Shipping Address (if different) ________________________________________________________

Accounts Payable Manager _________________________________________________________

Is this business a: Sole Proprietorship, Partnership or Corporation?

If Corporation: Year Inc. ______________________ State Inc. _____________________________

Federal Tax ID # __________________________________________________________________

Corporate Officers _________________________________________________________________

Principal Owner(s): ________________________________________________________________

Is PO# Required ? __________ Yes ___________ No

Bank Reference:

Name _________________________________ Acct# ________________ Phone ______________

Address _________________________________________________________________________

Business References:

Name __________________________________ Acct# _______________ Phone ______________

Address _________________________________________________________________________

Name __________________________________ Acct# _______________ Phone ______________

Address _________________________________________________________________________

Credit Terms:

1. Net due 30 days from billing date.

2. An account 60 days in age will be C.O.D. only, until the balance is paid in full. At that time a payment arrangement must be set up and followed through with as agreed upon or your credit line will be rejected. (It may also be rejected if this happens continuously.)

If credit is granted, I agree to pay by the terms outlined above and I understand that interest of 1.5% per month will be charged on past due balances. I also agree to pay all attorney’s fees, court costs, collection costs and all other expenses which may be incurred in collecting past due balances or insufficient funds checks, as permitted by law.

Signature ______________________________________ Date _______________________________

Title __________________________________________ Phone ______________________________

Sales Tax Form

I, the undersigned purchaser, hereby certify that I am engaged in the business of selling, leasing or renting auto and body repairs or parts and that the tangible personal property described herein, which I shall purchase from above dealer will be resold, leased or rented by me; provided, however, that if any such property is used for any purpose other than retention, demonstration or display while holding it for sale, lease or rental in the regular course of business, it is understood that I am required to report and pay the tax measured by the purchase price of such property.

Purchaser’s Sales and Use Tax Number __________________________

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For Internal Use only:

ENL:________ REV: __________ ORION: ________NOTES:___________________________________