BUSINESS INFORMATION

Company Name:

Address:

City: State: Zip:

Purchaser Contact: E-MAIL:

Phone: Fax:

Corporation Partnership Individual

Number of Years

EIN# or SSN#

BANK INFORMATION

Bank Name:

Address:

Phone: Acct. #

Officer:

TRADE REFERENCES

Name:

Address:

Phone: Fax:

Account No.:

Name:

Address:

Phone: Fax:

Account No.:

Name:

Address:

Phone: Fax:

Account No.:

ACCOUNTS PAYABLE INFORMATION

Purchase order Required: Yes No

Accounts Payable Contact: E-MAIL:

Phone:

Invoices Mailed To:

The above information is submitted for the purpose of obtaining credit, intending that these facts should be relied upon. If credit is extended, I (we) hereby agree to cooperate, in consideration of this privilege, by making a settlement on or within 30 days from the date on the invoice. If our Company does not meet the terms stated above, we (the Customer) will be responsible for payment of all collection agency fees.

Authorized Agent - Signature

Authorized Agent - Print

Date

Contact information if you chose to send via mail or fax:

TTA/C Parts Corporation
1705 PEACHTREE RD.
MESQUITE, TX. 75180
Phone: 972-289-9696 Fax 972-288-8486