test - parklandcollection

New applicatio Form

Name/Address

First Name:

Second Name:

Middle initial:

Title:

Name of business

Tax I.D. Number (Copy of StateIssued Tax ID Must be Submitt

State

City

ZIP

Phone

Company Information

Type of Business

In Business since

Legal Form Under Which Business Operates:
Corporation Partnership Proprietorship

If Division/Subsidiary, Name of Parent Company

In Business since

Name of Company Principal Responsible for Business Transactions:

Title

City

State

ZIP

Phone

Bank Refference

Institution Name:

Checking Account#

Address

Phone

Trade References

Company Name

Contact Name

Address

Phone

Account Opened Since

Credit Limit

Current Balance

Customer certifies that the above stated information is true and correct as of the date of this application, and agrees to update this information when changes occur. Customer further understands and agrees that invoicing, billing, and payment terms on customer account will be as per the terms set forth in each order/invoice. Customer will be responsible for all cost Parkland Collection incurs in collection of any delinquent account, including legal fees. Customer authorizes Parkland Collection LLC. to obtain information regarding their respective credit, as permitted by law, for this credit application or future credit applications, and to retain this information on file.

Shipping Information

Drop Ship Carrier

3rd Party Account #

Order Information

Order Confirmation Required
YesNo

Order Confirmation Email

Tracking Confirmation Required
YesNo

Tracking Confirmation Email

Invoice Information

Accounts Payable Contact Name

Contact Email

Contact Phone Number

Preferred Invoice Method
EmailAddress

Invoice Email

Invoice Street Address

Company Name

Credit Card Information

Type of card
visaMaster CardAmerican ExpressDiscover

Credit Card #

Credit Card Security Code

Credit Card Expiration Date

Name as it appears on Credit Card

Signature

Date

Credit Card Address

Authorized User

I, from , hereby authorize Parkland Collection LLC to charge my credit card account for purchases and incidental shipping charges or charges back billed to Parkland Collection. I authorize Parkland Collection to keep this card on file for all future purchases or order-related incidentals mentioned above.