New Customer Account Application

FAX FORM TO: 563-388-5425 ORMail To: 209 W 76th St, Davenport, IA 52806

Please Tell Us About Yourself:

Name: ______SSN: ______

Address: ______City, State, Zip: ______

Phone: ______Fax: ______

Email: ______

If You Own A Business:

Business Name (If Applicable): ______

DBA: ______Tax ID: ______

Contact Person(s): ______

Address: ______City, State, Zip: ______

Phone: ______Fax: ______

Email: ______Website: ______

Type of Business:

____ Private Corporation ____ Public Corporation ____ LLC ____ LLP

____ Sole Proprietorship____ Partnership ____ Other: ______

How Will You Pay:

___ Credit Card ___ Check ___Cash ___COD (IF Check, Fill Out Check Form)

Signed By: ______Date: ______

Printed Name: ______

Check Pay Form

Bank Reference

Bank Name: ______

Routing #: ______

Account #: ______

Address: ______

City, State, Zip: ______

Name Of Authorized Signer / Title / Date of Birth / SSN# / Drivers License # / State of DL

PLEASE NOTE AND INITIAL NEXT TO:

______If account is authorized to purchase on an open account, be it understood that all purchases due to payable within 30 days from purchase date. The undersigned official, to induce the granting of credit to the above named firm, hereby personally guarantees the company’s credit. If for whatever reason, the customer goes into default, they will be responsible for all fees incurred. Accounts not paid in full by the due date are subject to a service charge at the highest rate allowed by law. All dishonored checks returned for any reason will be assessed a $30.00 fee per occurrence.

  • IF ANYTHING IS DAMAGED OR THERE ARE SHORTAGES, YOU MUST REPORT THIS TO US WITHIN5 DAYS OF DELIVERY OR NO CREDIT OR REPLACEMENTS WILL BE GIVEN.
  • NO CREDIT IS GIVEN ON PARTS RETURNED MORE THAN 90 DAYSAFTER PURCHASE.
  • ANY RETURNS AFTER 90 DAYS MAY BE SUBJECT TO A RESTOCKING FEE.
  • ALL RETURNED PARTS MUST NOT HAVE BEEN PREVIOUSLY INSTALLED AND BE IN ORIGINAL PACKAGING IN ORDER TO RECEIVE CREDIT.

Signed By: ______Date: ______

Credit Card Form

Credit Card Information:

Card Type: _____ Visa ______Mastercard ______Discover

Name on Card: ______

Credit Card Number: ______-______-______-______

Expiration Date: ______/______

CVV Code: ______

Billing Address:

Address: ______

Address: ______

City, State, Zip: ______

PLEASE NOTE AND INITIAL NEXT TO:

______You must provide up to date credit card information to us to keep credit card on file current. If account does not have a valid credit card on file and you place an order, we make one attempt to get updated information. If we cannot get this information before the order is supposed to ship out, we will NOT ship the items. You are responsible for keeping up to date information on file. If other arrangements need to be made for payment, you need to contact us within 3 days or the order will be canceled.

  • IF ANYTHING IS DAMAGED OR THERE ARE SHORTAGES, YOU MUST REPORT THIS TO US WITHIN5 DAYS OF DELIVERY OR NO CREDIT OR REPLACEMENTS WILL BE GIVEN.
  • NO CREDIT IS GIVEN ON PARTS RETURNED MORE THAN 90 DAYSAFTER PURCHASE.
  • ANY RETURNS AFTER 90 DAYS MAY BE SUBJECT TO A RESTOCKING FEE.
  • ALL RETURNED PARTS MUST NOT HAVE BEEN PREVIOUSLY INSTALLED AND BE IN ORIGINAL PACKAGING IN ORDER TO RECEIVE CREDIT.

Signed By: ______Date: ______