RETAILER APPLICATION - PARTS
INSTRUCTIONS
Online via desktop or laptop 1 ) Open the Application in your web browser . 2 ) Select the DOWNLOAD PDF button ( ) from the left sidebar . 3 ) Once downloaded to your desktop or laptop , select any field to type in your answers .
( This feature requires Adobe Acrobat Reader . If you don ’ t have it , go to https :// get . adobe . com / reader to install the free Acrobat Reader .)
We recommend you save the PDF Application frequently so as not to lose your work .
( To save select FILE > SAVE AS . Rename the file with your company name .)
4 ) Once all fields are completed , attach the saved PDF file to an email and send to ncd @ collinsdistribution . com 5 ) You will be notified once your application has been approved .
If you prefer not to complete the Application online Print , complete and mail the Application to our New Customer Development department .
COMPANY INFO Business Name : __________________________________________________________________________________________________ OE #: __________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Phone : ___________________________ Fax : ___________________________ Email : ________________________________________________________________
SHIPPING ADDRESS ( if different from above ): Address ( city , state , zip ): ___________________________________________________________________________________________________________________
Federal Tax ID #: __________________________________________ State Sales Tax ID #: __________________________________________ Yrs . in Business : _____ Type of Ownership : Sole Proprietor ___ C Corp ___ S Corp ___ All Other LLCS — Specify _______________ Partnership ___ Trust / Estate ___ Other _______________ Owner ’ s Name # 1 : _____________________________________________ Title : ____________________________ SS #: ____________________ Ownership %: _____ Owner ’ s Name # 1 : _____________________________________________ Title : ____________________________ SS #: ____________________ Ownership %: _____
BANK REFERENCES CHECKING : Bank Name : _________________________________ Acct No .: ________________________ Contact Name & Phone No .: ____________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ SAVINGS : Bank Name : _________________________________ Acct No .: ________________________ Contact Name & Phone No .: ____________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ LOAN / OTHER : Bank Name : _________________________________ Acct No .: ________________________ Contact Name & Phone No .: ____________________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________
TRADE REFERENCES PREFERRED PAYMENT METHOD : Business Credit Card ___ Net 15 ___ Net 30 ( Note : Net 15 & Net 30 requires credit check at bank and meeting certain other criteria .)
Company Name # 1 : _________________________________ Acct No .: ________________________ Contact Name & Phone No .: _____________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________ Company Name # 2 : _________________________________ Acct No .: ________________________ Contact Name & Phone No .: _____________________________ Address ( city , state , zip ): ___________________________________________________________________________________________________________________
SIGNATURE Signature : ___________________________________________________________________________ Date : ______________________________________________ Printed Name : ________________________________________________________________________ Title : _______________________________________________
PERSONAL GUARANTY OF OBLIGATIONS
In consideration of your extension of credit to the above-named applicant ( hereinafter referred to as “ Company ”), the undersigned , having a financial interest in the Company , ( thereinafter “ Guarantors ”) hereby jointly and severally guarantee the payment of all of the Company ’ s present and future indebtedness to Collins Distribution , regardless of whether Company is presently indebted to Collins Distribution . If Company fails to pay any amount within 30 days after it becomes due , the undersigned jointly and severally agree to pay such amount on demand , together with reasonable attorney ’ s fees and costs incurred in collection of the delinquent balance . This is a continuing guarantee and is irrevocable . This instrument is intended to cover all of Company ’ s present and future indebtedness or liability , and all extension or renewals thereof . In the event of any legal action involving any such indebtedness or liability , the parties agree that venue shall be in Grant County , Indiana . With respect to all disputes relating to obligations of the Company , Company and Guarantors submit themselves to the personal jurisdiction of the state courts of appropriate subject matter jurisdiction in Grant County , Indiana .
Guarantor Signature : __________________________________________ Printed Name : __________________________________________ Date : ________________ Witness Signature : ____________________________________________ Printed Name : __________________________________________ Date : ________________
Collins Distribution . 1139 S . Baldwin Avenue , Marion , IN 46953 . ( 800 ) 825-1100 . fax ( 765 ) 662-9959 . ncd @ collinsdistribution . com