Business Contact Information

Title:

Company name:

Phone:

Fax:

E-mail:

Registered company address:

City:

State:

ZIP Code:

Date business commenced:

Sole proprietorship:

Partnership:

Corporation:

Other:

Business and Credit Information

Primary business address:

City:

State:

ZIP Code:

How long at current address?

Telephone:

Fax:

E-mail:

Bank name:

Bank address:

Phone:

City:

State:

ZIP Code:

Type of account

Account number

Savings

Checking

Other

Business/trade references

Company name:

Address:

City:

State:

ZIP Code:

Phone:

Fax:

E-mail:

Type of account:

Company name:

Address:

City:

State:

ZIP Code:

Phone:

Fax:

E-mail:

Type of account:

Company name:

Address:

City:

State:

ZIP Code:

Phone:

Fax:

E-mail:

Type of account:

Agreement

1. All invoices are to be paid by the 10^th of the month following the month of purchases.

2. By submitting this application, you authorize Pit Stop Auto Repair Shops, Inc. to make inquiries into the banking and business/trade references that you have supplied.

Signatures

Printed Name

Printed Name

Signature

Signature

Title

Title

Date

Date