FMD, LLC 8 Progress Street Edison, NJ 08820 800.526.0910 or 908.561.7300 www.millmans.com
Remit Payment to: FMD, LLC
Frank Millman Distributors 32415 Collection Center Dr Chicago, IL 60693-0324
Frank Millman Distributors 8 Progress Street Edison, NJ 08820-1100
Robert Elgart Automotive 1 Winding Dr. St. 201 Philadelphia, PA 19131
Applicant: Please read the following before completing this form. Applicant represents that the information given in this application is complete and accurate and authorizes FMD, LLC (“Seller”) or its authorized credit agent to check with credit reporting agencies, credit references, and other sources, including banks, Seller deems appropriate in considering this application and subsequently for any legal purpose. READ THE ATTACHED AGREEMENT AND SIGN THE “SIGNATURE” SECTION BEFORE SUBMITTING THIS APPLICATION CUSTOMER INFORMATION Company Name (Full Legal Name) DBA (Doing Business As)
Billing Address City State Zip Code
Physical Address (Shipping Address)
Business Type:
Billing Contact Name
Phone #
Fax #
Email Address:
Year Established
Type of Business
Number of Locations
Credit Limit Requested $
Business Structure:
_____ LLC
State of Incorporation _____________________
_____ Corporation (or)
Year of Incorporation ___________
_____ Sole Proprietorship Average Monthly Purchases: Are your purchases Tax Exempt? $ _____________________
_____ Partnership Federal ID #
Have you ever filed bankruptcy? _____ Government Agency
Yes _______ (complete below) No ________
________________
What type? ______________________________
What year? ________________
Tax Exempt #
TAX WILL CONTINUE TO BE CHARGED ON ALL INVOICES UNTIL THE TAX EXEMPT CERTIFICATE IS RECEIVED. CUSTOMER WILL BE RESPONSIBLE FOR ALL TAX UNTIL CERITIFICATE IS RECEIVED
Yes ______
No ______
___________________
Purchasing Manager (Buyer)
Phone #
Fax #
Email Address:
Bank Reference (Required)
Bank Acct Number: ______________________________________________________
Name of Bank: _______________________________________
Address: ______________________________________________
Email Address _____________________________
Phone: ________________________ Contact ________________________________________
Trade References (Required)
Phone _________________________ Fax ______________________________ Name ________________________________________________________
City/State ________________________________
Contact _____________________________________
Acct # ______________________________
Name ________________________________________________________Phone _________________________ Fax ______________________________
City/State ________________________________
Contact _____________________________________
Acct # ______________________________
Name ________________________________________________________
Phone _________________________ Fax ______________________________
City/State ________________________________
Contact _____________________________________
Acct # ______________________________
The undersigned confirms that the above information is true and accurate and hereby authorizes FMD, LLC (Company) to obtain credit and/or financial information from the name and references listed above. If given open terms of credit with (Company), the indersigned company promises to pay for all purchases in accordance with (Company) terms. If not a corporation, the undersigned company/owner personally guarantees payment of all invoces. If at any time the undersigned company is unable to meet its financial obligation with (Company), the undersigned agrees to pay for legal, court or any other fees necessary to collect unpaid invoices.
NO RETURNS ON SPECIAL ORDERS OR SEASONAL MERCHANDISE.
Discover/Mastercard/Visa/American Express Available. Service Charge for returned checks $20.00. Collection Fee of 25% will be applied if account is sent to third party for collections.
Payment Terms:
__________Net 10th __________Net 30 Days
Owner:
Manager:
________________________________________________
____________________________________________ Date: _______________
Approved Credit Limit: _________________ By: ____________________
Sales Person: ___________________________________________
Made with FlippingBook - professional solution for displaying marketing and sales documents online