Full Name of Individual or Firm:

Billing Address:

City, State, Zip:

Shipping Address
(if different than above):

City, State, Zip:

Phone Number:

Cell Phone Number:

Fax Number:

E-mail Address:

Web Site:

Number of years in business:

Are purchase orders required?

Yes   No

Check one:   Corporation   Partnership   Individual

If corporation, give Federal ID#:

Owner's Last Name:

Social Security #:

Title:

Other Owner's Last Name:

Social Security #:

Title:

Contacts

President (unless listed above):

Sales Manager:

Parts Manager:

Service Manager:

Please check type of business

Beverage
Utilities
Refuse
Schools
Ag. or Farming
Machine Shop
Individual
Owner Operators/Truck
Fleet Trkg.-10 or More Trks.
Trucking 2-9 Trucks
Custom Harvesters
Bus Fleet
Org. Equipmt. Manuf.

Construction
Water Well Drillers
Automotive Jobber Only
Automotive Jobber/Installer
Automotive Installer Only
Automotive Fleet
Elec. Contractors-Gen Sales/Serv.
Gov.-City-County-State-Military
Resale/Parts-Repair Shops
Feed Lots and Related Industries
Petroleum Related Companies
Other

If Other, please specify:

* If applicable, we must have a sales tax exemption form filled out and signed for our files.

Credit References

1st Business Name:

Address:

City, State, Zip:

Phone:

2nd Business Name:

Address:

City, State, Zip:

Phone:

3rd Business Name:

Address:

City, State, Zip:

Phone:

4th Business Name:

Address:

City, State, Zip:

Phone:

Credit Agreement

Upon the acceptance for credit, we agree to pay the billed amount before the 10th of the month following the purchase (net 10th prox.), unless otherwise stated on the individual billing. We agree that if billed amount is not paid the last day of the month following the month of purchase, unless otherwise stated on the individual billing, we will pay all interest charged on the overdue balance at a periodic rate of 1½% per month (18% annual percentage rate.)

This credit agreement shall be construed, governed, interpreted, and applied in accordance with the laws of the State of Missouri. The Clay County Circuit Court shall have jurisdiction over all controversies and/or litigation which may arise with respect to the negotiations, executions, interpretations, and compliance with this credit agreement. The parties hereby waive any other venue to which they may be entitled by virtue of domicile or otherwise.

We certify that all information on this form is warranted to be correct and that we fully understand your credit terms of the net 10th prox. we hereby authorize Central Power Systems & Services Inc. to investigate the references listed pertaining to our credit and financial responsibility and to release information about their credit experience with us.

Name of Company:

Date:

By:

Title:

Personal Guarantee

In consideration of the extension of credit to applicant, the undersigned personally guarantees payment of all advances, credits and related service charges made by Central Power Systems & Services Inc. to applicant, together with collection costs, including reasonable attorney's fees where allowed by law.

I Accept Terms & Conditions

*REQUIRED FIELDS