PARTS & SERVICE

RENTAL

LEASE

Company Information:

Company Name:

Phone #:

Fax #:

Owners Name:

Email:

Address:

City,State,Zip:

Corporation - State Incorporated :

Partnership:

Sole Proprietorship:

Other:

DBA(if any):

Type of Business:

Year Business Started:

Current VVG customer:

Which Company:

Name and Social Security Number Of Principal(if other than corporation):

D-U-N-S #:		Federal Tax ID#:		PO Required?:
Credit Amount Requested:

Check box if you wish to receive invoices via email.

Resale?

Yes ...if yes, please submit a completed resale card.

Trade Reference:

Company Name:	Phone #:	Fax #:
Type of Business:	Years doing business with:
Full Address:		Account#:

Company Name:	Phone #:	Fax #:
Type of Business:	Years doing business with:
Full Address:		Account#:

Company Name:	Phone #:	Fax #:
Type of Business:	Years doing business with:
Full Address:		Account#:

Truck Insurance Informaton (rental or lease):

Liability – Broker:

Contact Name:

Phone #:

Physical Damage – Broker:

Contact Name:

Phone #:

READ BEFORE SIGNING:

Applicant has completed this Credit Application for the purpose of procuring and maintaining credit on an open account basis with Velocity Vehicle Group & Affiliates (“Velocity”), and Applicant and the signer below (who warrants due authorization from Applicant for all matters stated herein) certify that all statements are true. Applicant and the undersigned have authorized Velocity to check credit references and to verify employment for applicant and any guarantor. Applicant and the undersigned have also authorized Velocity to obtain from any source all credit information concerning the referenced applicant and any proposed guarantor (including but not limited to credit references, employment verification, financial statements, tax returns, information concerning loans, information concerning depository and other accounts, and credit reporting agency information) (collectively the “Credit Information”), to share all Credit Information with all any and all affiliates of Velocity, and to provide all Credit Information to any and all third parties having a legitimate interest in any transaction for which the credit application is made. Applicant and the undersigned acknowledge that the credit sought is solely for a business purpose and not for any personal, household or family purpose.

Applicant and the undersigned understand and agree that all charges are due and payable 30 days following the date of charge. In the event it becomes necessary for Velocity to incur collection costs or institute suit to collect costs or institute suit to collect any amount due under this agreement, applicant promises to pay such additional costs, interest, including reasonable attorney’s fees. Velocity has the right to deny credit or limit the amount of credit extended, for any cause or no cause.

By checking this box and filling out your name in the signature field, you are authorizing us to check your credit history

__________________________________			09/01/2018
Signature	Printed Name	Title	Date