New Customer Application

Minimum Order $25.00

Date:

Contact: E-Mail:

Business Legal Name:

Branch Locations: Yes No

Physical Address:

City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: -

Phone: Fax:

Billing Address (If different than Physical):

City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: -

Shipping Address (If different than Physical):

City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: -

Business Information

Business Type: OEM Dealer End User     If Corporation, please provide TIN:

Years in Business: Number of Employees: Estimated Purchases ($)/Month     Tax Exempt No. State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Please briefly explain the nature of the business:

Principal Owner(s) / Officers

President:

Phone: Ext.: E-Mail:

Accounts Payable Manager:

Phone: Ext.: E-Mail:

Purchasing Manager:

Phone: Ext.: E-Mail:

Type of account being applied for: Credit Card Open Account

If applying for an open account, TERMS ARE NET 30 DAYS ON ALL INVOICES. AFS RESERVES THE RIGHT TO CHARGE 1.5% INTEREST PER MONTH ON ALL PAST DUE AMOUNTS.

For open accounts, TRADE REFERENCES ARE REQUIRED. FORMS NOT INCLUDING FAX NUMBERS WILL BE REJECTED.

Trade References

Reference 1

Firm:  

Address:

City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:

Phone: Fax:

Reference 2

Firm:  

Address:

City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:

Phone: Fax:

Reference 3

Firm:

 Address:

City: State: AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code:

Phone: Fax:

Authorized Purchaser:

Applications submitted online: Signature Page must be mailed to Alternative Fuel Systems, Inc., Attn: Credit Department, 3232 S. Nordic, Arlington Heights, IL., 60005, to complete the process. Click here to download the signature page.

By submitting this online application, I hereby grant permission to Alternative Fuel Systems, Inc. to check with the above named references in order to establish an open account.