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MARYLAND
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MINNESOTA
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MISSOURI
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NEW JERSEY
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NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
PUERTO RICO
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEWFOUNDLAND
NORTHWEST TERRITORIES
NOVA SCOTIA
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
SASKATCHEWAN
YUKON
Zip/Postal Code
County
Phone
Fax
Sales Tax Exemption #
Desired Credit Limit $
Note: A copy of your resale certificate must be forwarded to the Credit Department in order to avoid the imposition of sales tax.
Business Type
Corporation
Partnership
Sole Owner
Date Established
Company listed in Dun & Bradstreet?
Yes
No
If Yes, Dun's #
For Corporations:
Name/Title of Officers...
Additional Officers...
For other business types:
Name of Owner(s)
Business Bank
Account #
Street Address
Street Address 2
City
Country
Ascension
Andorra
United Arab Emirates
Afghanistan
Antigua & Barbuda
Anguilla
Albania
Armenia
Netherlands Antilles
Angola
Antarctica
Argentina
American Samoa
Austria
Australia
Aruba
Aland Islands
Azerbaijan
Bosnia and Herzegowina
Barbados
Bangladesh
Belgium
Burkina Faso
Bulgaria
Bahrain
Burundi
Benin
Bermuda
Brunei Darussalam
Bolivia
Brazil
Bahamas
Bhutan
Bouvet Island
Botswana
Belarus
Belize
Canada
Cocos (Keeling) Islands
Congo, Democratic Republic of
Central African Republic
Congo, People's Republic of
Switzerland
Cote d'Ivoire
Cook Islands
Chile
Cameroon
China
Colombia
Costa Rica
Serbia and Montenegro
Cuba
Cape Verde
Christmas Island
Cyprus
Czech Republic
Germany
Djibouti
Denmark
Dominica
Dominican Republic
Algeria
Ecuador
Estonia
Egypt
Western Sahara
Eritrea
Spain & Canary Islands
Ethiopia
Finland
Fiji
Falkland Islands
Micronesia
Faroe Islands
France
Gabon
United Kingdom
Grenada
Georgia
French Guiana
Ghana
Gibraltar
Greenland
Gambia
Guinea
Guadeloupe
Equatorial Guinea
Greece
South Georgia/South Sandwich I
Guatemala
Guam
Guinea-Bissau
Guyana
Hong Kong
Heard and McDonald Islands
Honduras
Croatia
Haiti
Hungary
Canary Islands
Indonesia
Ireland
Israel
India
British Indian Ocean Territory
Iraq
Iran
Iceland
Italy
Jersey (British Isles)
Jamaica
Jordan
Japan
Kenya
Kyrgystan
Cambodia
Kiribati
Comoros
St. Kitts and Nevis
Korea, Democratic People's Rep
Korea, Republic of
Kuwait
Cayman Islands
Kazakstan
Lao People's Democratic Republ
Lebanon
Saint Lucia
Liechtenstein
Sri Lanka
Liberia
Lesotho
Lithuania
Luxembourg
Latvia
Libyan Arab Jamahiriya
Morocco
Monaco
Moldova
Madagascar
Marshall Islands
Macedonia (FYROM)
Mali
Myanmar
Mongolia
Macau
Northern Mariana Islands
Martinique
Mauritania
Montserrat
Malta
Mauritius
Maldives
Malawi
Mexico
Malaysia
Mozambique
Namibia
New Caledonia
Niger
Norfolk Island
Nigeria
Nicaragua
Netherlands
Norway
Nepal
Nauru
Niue
New Zealand
Oman
Panama
Peru
French Polynesia
Papua New Guinea
Philippines
Pakistan
Poland
St. Pierre and Miquelon
Pitcairn
Puerto Rico
Portugal
Palau
Paraguay
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saudi Arabia
Solomon Islands
Seychelles
Sudan
Sweden
Singapore
St. Helena
Slovenia
Svalbard and Jan Mayen Islands
Slovakia
Sierra Leone
San Marino
Senegal
Somalia
Suriname
Sao Tome and Principe
El Salvador
Syrian Arab Republic
Swaziland
Tristan da Cunha
Turks and Caicos Islands
Chad
French Southern Territories
Togo
Thailand
Tajikistan
Tokelau
East Timor
Turkmenistan
Tunisia
Tonga
Turkey
Trinidad and Tobago
Tuvalu
Taiwan, Province of China
Tanzania
Ukraine
Uganda
United States Minor Outlying I
United States of America
Uruguay
Uzbekistan
Vatican City State
Saint Vincent and the Grenadin
Venezuela
Virgin Islands, British
Virgin Islands, U.S.
Viet Nam
Vanuatu
Wallis and Futuna Islands
Samoa
Nevis (St. Kitts & Nevis)
Somaliland
St. Barthelemy (St. Barts)
Yemen
Mayotte
South Africa
Zambia
Zimbabwe
State/Province
OTHER
ALABAMA
ALASKA
ARIZONA
ARKANSAS
CALIFORNIA
COLORADO
CONNECTICUT
DELAWARE
FLORIDA
GEORGIA
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUSIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UTAH
VERMONT
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
PUERTO RICO
ALBERTA
BRITISH COLUMBIA
MANITOBA
NEW BRUNSWICK
NEWFOUNDLAND
NORTHWEST TERRITORIES
NOVA SCOTIA
ONTARIO
PRINCE EDWARD ISLAND
QUEBEC
SASKATCHEWAN
YUKON
Zip/Postal Code
Phone
Is your company a member of any buying group?
Yes
No
If yes, which one?
Business References: (Please supply at least 3)
Company Name
Complete Address
Phone/Fax
Contact
Company Name
Complete Address
Phone/Fax
Contact
Company Name
Complete Address
Phone/Fax
Contact
We, the company, agree to maintain our account to the payment terms established by MARS. We further understand and agree that should our account become delinquent, we will be liable for interest on the unpaid balance as well as any collection fees incurred obtaining payment.
By "clicking the submit button below" I hereby attest that all information on this form is accurate and authorize the release of any pertinent credit information , requested by Motors and Armatures, relative to my account.
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Today's Date