National2Way Dealer Application





State

Zip

Telephone

E-mail

Business Type

# of employees

Years in business

 

Dunn & Bradstreet #

 

Tax ID#

 

AP Contact Name

 

AP E-mail

 

Bank/Savings & Loan Information


 

Name

Account#

Branch Address

Contact Name

Telephone

 

Credit Card Information


 

You can elect to have a credit card saved on file for order payment. Please note that a credit card can only be used for payment on orders less than $5,000.00.

To ensure security, the accounting department at national2Way will contact you for the expiration date and SEC code for this card.

National2Way practices secure credit card storage protocol.



Name on credit card

Card Number

National2Way inc. may keep this credit card information on file for orders through the date indicated below:

Date

 

Trade References


 

Company Name - First Reference

Contact Name - First Reference

Address

 

Telephone

E-mail




Company Name - Second Reference

Contact Name - Second Reference

Address

 

Telephone

E-mail





Credit Terms


 

1. Each invoice is due in 30 days.

2. At the discretion of National2Way Inc., any account with a delinquent balance can be placed on a cash basis.

3.Customer agrees to pay all reasonable attorney's fees, court costs and collection costs incurred by National2Way Inc. in enforcing these terms and conditions.

4. Customer authorizes National2Way to obtain credit reports, trade reports and bank references for the purpose of determining the extension or continuation of credit to the customer.

The undersigned warrants that all information is correct, has been read, accepted and agrees to be bound by all terms set forth in this document. It is understood and agreed that the undersigned specifically consents to National2Way's investigation of applicant's credit history and may utilize credit reporting services for information on the undersigned. Electronically submitted copies will be accepted as originals.

the Federal Equal Credit Opportunity Act/Regulation B, prohibits creditors from discriminating against applicants on the basis of race, color, national origin, sex, marital status, age (provided that applicant has the capacity to enter into a binding contract): because all, or part, of the applicants income derives from any public assistance program; or because the applicant has, in good faith, exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with the law concerning this credit is the Federal Trade Commission Division of Credit Practices, 6th and Pennsylvania Avenue NW Washington D.C., 20580



Officer/Owner Name

Title

Signature

Date

Telephone

E-mail