APPLICATION FOR ACCOUNT - PARTS OR SERVICE
Name / Trade Name
Address
City Postal Code
Phone Fax
Contact
Name of Principles Title
Name of Principles Title
Social Security Number
Numbers of Years in Business Truck #'s
Type of Firm: Partnership Proprietorship Corporation
Anticipated Monthly Purchases: $
P.S.T. Exempt #
G.S.T. Exempt #

BANKING INFORMATION
Bank Name
Contact
Address
Account Number
Phone Number / Area Code

TRADE REFERANCES
1
Company Name
Contact / Phone Number Ph#
Address
2
Company Name
Contact / Phone Number Ph#
Address
3
Company Name
Contact / Phone Number Ph#
Address
If credit is extended to you, who is authorized to charge on your behalf ?

AUTHORIZATION AND DATE
CONSENT: I (we) hereby authorize Harper Freightliner Inc. to obtain credit or other information as may be deemed necessary in connection with the establishment and maintenance of a credit account or for any other direct business required.

I (we) ( Company Name ) understand that accounts in arrears are subject to a service charge at a rate of 1 1/2 % per month on outstanding balances in excess of 30 days. Accounts not paid within 30 days are considered past due and may cause interruption in credit extended. I further agree to pay collection and / or legal fees incurred by Harper Freightliner Inc. in collection of any past due amounts
Application Date
Signed By:


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Your E-Mail Address