Express Towing and Recovery - Equipment Division phone number 813-661-1100 and automotive division phone number 813-661-1100
 
2116 Jelane Drive · Valrico, FL 33594
Main Office: (813) 643-8365 · Equipment Division: (813) 661-1100 · Heavy Towing Division: (813) 620-3040

CREDIT APPLICATION

DIRECTIONS: You can type your information right into this online form. No information is sent over the internet. When you click the "Print This Page" button at the bottom, your information will be printed to your printer. Next, after you have printed the application, sign it, and then fax it to us at: (813) 661-8636. We will need the original signed copy mailed to us. When you have finished printing the form, click "Close Window" to exit this application page.

IMPORTANT

THIS CREDIT APPLICATION WILL NOT BE PROCESSED UNLESS IT IS COMPLETED
FULLY AND SIGNED BY AN AUTHORIZED OFFICER OF THE BUSINESS OR CORPORATION.

GENERAL INFORMATION
TYPE OF BUSINESS: CORPORATION    PARTNERSHIP    PROPRIETORSHIP
NAME OF BUSINESS:  
FEIN:  
ADDRESS LINE 1:  
ADDRESS LINE 2:  
CITY:    STATE:   ZIP:
PHONE:    FAX:
CONTACT PERSON
OWNER INFORMATION
OWNER/PRESIDENT:
ADDRESS LINE 1:  
ADDRESS LINE 2:  
CITY:    STATE:   ZIP:
PHONE:    FAX:
TRADE REFERENCES
NOTE: LIST ONLY THOSE VENDORS THAT SELL TO YOU ON OPEN ACCOUNTS.
1. NAME:
TELEPHONE:
  ADDRESS:
ACCT#:
  CITY: STATE:
ZIP:
2. NAME:
TELEPHONE:
  ADDRESS:
ACCT#:
  CITY: STATE:
ZIP:
3. NAME:
TELEPHONE:
  ADDRESS:
ACCT#:
  CITY: STATE:
ZIP:


BANKING INFORMATION
TYPE OF ACCOUNT(S): SAVINGS CHECKING LOAN
BANK NAME:
ADDRESS:
TELEPHONE:
CITY:   STATE:
ZIP:
VENDOR INFORMATTION
IF ENTITLTED TO TAX EXEMPT STATUS LIST TAX NO.: ,
AND RETURN ENCLOSED TAX CERTIFICATE WITH THIS APPLICATION TO OUR OFFICE
DOES YOUR BUSINESS REQUIRE PURCHASE ORDERS? YES NO
LIST NAME(S) OF PERSON(S) AUTHORIZED TO PURCHASE FOR YOUR BUSINESS:
1. NAME:    TITLE:
2. NAME:    TITLE:
3. NAME:    TITLE:
TERMS AND CONDITIONS
  1. ALL INVOICES ARE NET DUE 10 DAYS FROM DATE OF SERVICE.
  2. ANY INVOICE PAST DUE AFTER THIRTY (30) DAYS SHALL ACCRUE A FINANCE CHARGE OF 1 1/2% PER MONTH (18% PER ANNUM) ON THE PAST DUE AMOUNT.
  3. IN THE EVENT OF DEFAULT, THE BUYER AGREES TO PAY ALL REASONABLE COLLECTION AND ATTORNEY FEES, INCLUDING COURT COSTS
I HAVE READ AND UNDERSTAND THE ABOVE TERMS AND CONDITIONS.  I HEREBY CERTIFY THAT THE BUSINESS/CORPORATION LISTED HEREIN IS LICENSED AND AUTHORIZED TO CONDUCT BUSINESS WITHIN THE STATE OF FLORIDA.
SIGNATURE:   ___________________________________________ TITLE:

DO NOT WRITE BELOW THIS LINE

CREDIT APPROVED BY:________________________________   DATE: ____________________ 

 ACCT #:___________________   CREDIT LIMIT:___________________