Cash On Delivery

This option provides flexibility for buyers who prefer to inspect items before payment or do not have access to immediate electronic payment methods.

Do You Require Purchase Orders?

Yes

Legal Business Name

First Name

Last Name

Doing Business As (DBA)

Phone Number

Billing Address

Address

City

State

Zip Code

Shipping Address

Same as billing

Address

City

State

Zip Code

Federal ID

Business Type

Is Business Incorporated?

Yes

If Yes, Which State?

Year Established

Check Appropriate Box For Federal Tax Classification

Sole Proprietor

Corporation

LLC

Other

Ownership (Name of Parent Company)

Parent Company Address (If Different)

City

State

Zip Code

Name

Title

Home Address

City

State

Zip Code

Phone Number

Current Year's Revenue ($)

Name

Phone Number

Fax Number

Address

City

State

Zip Code

Types of Accounts

Checking

Savings

Other

Account Number

Name

Title

Online Access

Admin

View Only

Order entry only (No billing or programs)

Order entry only (No billing)

Name

Title

Online Access

Admin

View Only

Order entry only (No billing or programs)

Order entry only (No billing)

Are Your Account Receivable And/Or Inventory Pledged As Security?

Yes

THE ABOVE INFORMATION THAT WAS GIVEN IS FOR THE PURPOSE OF OBTAINING CREDIT INFORMATION AND AUTHORIZES OUR BANK(S) OF RECORD TO RELEASE INFORMATION REGARDING OUR ACCOUNT(S). I/WE AUTHORIZE THE FIRM, TIRE DISTRIBUTOR XPERTS, LLC, ITS AGENTS AND ASSIGNS, TO WHOM THIS APPLICATION IS MADE TO INVESTIGATE THE REFERENCES LISTED PERTAINING TO MY/OUR CREDIT AND FINANCIAL RESPONSIBILITY. I/WE AUTHORIZE THE FIRM, TIRE DISTRIBUTOR XPERTS, LLC TO RUN ANY CREDIT REPORT (PERSONAL OR BUSINESS) THAT IS DEEMED NECESSARY TO ESTABLISH FINANCIAL RESPONSIBILITY. UPON FAILURE OF BUYER TO PAY ANY INDEBTEDNESS WHEN DUE, TIRE DISTRIBUTOR XPERTS, LLC MAY DECLARE THE ENTIRE BALANCE OF ALL INDEBTEDNESS IN DEFAULT. IN THIS EVENT, UPON NOTICE TO THE BUYER, THE ENTIRE BALANCE OF ALL INDEBTEDNESS SHALL BECOME IMMEDIATELY DUE AND PAYABLE. IN THE EVENT OF DELINQUENCY OR DEFAULT BY THE BUYER, I/WE AGREE TO PAY 1 ½% PER MONTH SERVICE CHARGE ON PAST DUE AMOUNTS AND PAY LEGAL AND ATTORNEY FEES IN COLLECTION OF ACCOUNT IS NECESSARY.

VENUE: I UNDERSTAND AND CONSENT THAT THIS AGREEMENT IN ENTERED INTO & IS GOVERNED BY THE LAWS OF THE STATE OF CALIFORNIA SUBMIT TO ITS JURISDICTION.

Date

Authorized Signature

Name

Title

DISHONORED CHECKS / ELECTRONIC FUNDS TRANSFER

Pursuant to California Civil Code Section 1719, any person who presents a check on insufficient funds shall be liable to the payee for the amount of the check, and a service charge payable to the payee not to exceed $25.00 for the first check, and $35.00 for each subsequent check to that payee.

A person writing an NSF check is liable for treble (three times) damages under California Civil Code Section 1719 unless that person pays the face amount of the check, the service charge, and the cost of mailing a written demand by certified mail with 30 days of mailing the notice. The treble damages shall not be less that $100.00 nor more that $1,500.00

Please provide a completed W-9 and any applicable sales tax documentation required by your state, including but not limited to:

Sales Tax Permit
Reseller Permit
Resale Certificate

Failure to provide the required documentation may result in sales tax being charged on purchases.

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