CREDIT APPLICATION

Company Name

Name of Owner or Officer of Corporation *

Street Address*

Mailing Address*

City*

State*
SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip*

Contact Person *

Phone *

A/P Manager Name *

Fax *

Email Address of Purchaser *

Type of Business *
corporationpartnershipproprietorship

FED EIN#

SS#

SS#

Year Business Started *

Credit Line Requested *

Total Vehicles *

Tractors *

Trailers *

Straight Trucks *

Other *

Are you exempt from PA, NJ, MD, NY, or VA sales tax? *
YesNo

Bank References

Bank Name *

Contact *

Account # *

Phone *

Local Trade References (Include Name, Address, Phone Number, Fax Number)
Reference 1

Name

Address

Phone Number

Fax Number

Account Number

Type of Business

Reference 2

Name

Address

Phone Number

Fax Number

Account Number

Type of Business

Reference 3

Name

Address

Phone Number

Fax Number

Account Number

Type of Business

Billing Requirements

Is a purchase order required? *
YesNo

Are you exempt from Federal Excise Tax? *
YesNo

STTC distributes monthly statements via fax or email.
Please enter fax number or email address to which statements should be sent:

Fax:

Email:

Are you National Account? If YES, please enter your account number below. *
YesNo

Michelin Account Number

Goodyear Account Number

Yokohama Account Number

List any special billing requirements:

Authorization
I hereby authorize Service Tire Truck Centers, Inc. or any Credit Bureau employed by Service Tire Truck Centers to investigate the references herein listed. If I do not pay the sums due within the agreed-upon terms, I agree to pay, in addition to sums, a finance charge of 1.5% per month on the net overdue amounts, plus 40% of the principal balance for the purpose of legal and collection fees if necessary.

Name of Authorized Representative of Company *

Title of Authorized Representative of Company *

Date *