CROSSROADS AUTOMOTIVE GROUP

Parts/Service Application

*Name of Business

*Physical Street Address:

*City:

*State:

*Zip Code:

*Billing Address:

*City:

*State:

*Zip Code:

*Phone

*Sole Owner:

*Partnership:

*Corporation:

*Tax Exempt (if exempt please include a copy of tax exemption form NC E-595E and ST-10): Yes No

*Business Founded:

*Nature of Business:

*Accounts payable contact:

*Phone:

*Fax:

*Zip Code:

Trade or Credit Reference

*Name:

*Phone:

*Address:

Name:

Phone:

Address:

Name:

Phone:

Address:

*Is purchase order required?** Yes No

**if required who is authorized to sign?

By clicking this box, I agree to receive in-person or automated telemarketing calls and texts from Dealer Auto Parts Source at the number I entered. I understand that my consent is not required for purchase.

BY SUBMITTING THIS FORM YOU CONSENT TO THE FOLLOWING CREDIT AGREEMENT:

I/We herby authorize all the above named persons or companies to release Crossroads Automotive Group and such information with regard to my/our financial conditions as may reasonably have a bearing on this application.
I/We understand that account statements will be mailed on the last business day of the month and that payment in full is due by the 10th of the following month. Past due amounts will be subject to a finance charge of one and a half percent (1.5%) monthly (18% annual interest rate) to be computed on the previous month’s balance after payments and credits are deducted.
I/We understand that all credit may be terminated without notice.
I/We understand that if the account is not used within nine months I/We must reapply.
It if becomes necessary to collect any indebtness, through an attorney or otherwise, I/We agree to pay all cost of collection.