The Heim Group - Replacement Parts

* - denotes required fields

BILLING INFORMATION

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Billing Contact Name:

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Billing Company Name:

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Billing Address 1:

Billing Address 2:

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Billing City:

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Billing State:

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Billing Zip:

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Billing Phone:

Billing Fax:

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Billing Email:

Same Address for Shipping?

SHIPPING INFORMATION

Shipping Contact Name:

Shipping Company Name:

Shipping Address 1:

Shipping Address 2:

Shipping City:

Shipping State:

Shipping Zip:

CONTACT INFORMATION

Purchasing Contact:

Purchasing Phone:

Purchasing Fax:

Purchasing Email:

GENERAL INFORMATION

Federal Tax ID:

Date Business Established:

Check which is applicable to you:

Corporation
General Partnership
Limited Partnership
LLC
Sole Proprietorship
Other

Have you or any of your affiliates ever had credit with us before?

Yes No
If yes, under what name?

TRADE REFERENCES

Trade #1 Name:

Trade #1 Address 1:

Trade #1 Address 2:

Trade #1 City:

Trade #1 State:

Trade #1 Zip:

Trade #2 Name:

Trade #2 Address 1:

Trade #2 Address 2:

Trade #2 City:

Trade #2 State:

Trade #2 Zip:

BANK REFERENCES

Bank Account #

Phone:

Name of Bank:

Contact Person:

Have you or your officers or affiliates ever filed a petition in bankruptcy?

Yes No

Are you subject to any litigation?

Yes No
If yes, under what name?

Are you current in meeting your other financial obligations?

Yes No

We declare that the above information is true, correct and complete and is given to induce Heim L.P. to extend credit. We authorize Heim L.P. to make such credit investigation as it sees fit, including contacting the above trade references and banks and obtaining credit reports. We authorize all trade references, banks and credit reporting agencies to disclose the Heim L.P. any and all information concerning the financial and credit history of my company.

Name of Company:

Authorized Signature:

Title: