Credit Application - Cooling Concepts

Company Name *

Company Contact *

Phone *

Fax *

Email *

Email

Confirm Email

Registered Company Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date Business Commenced *

FEIN *

Type of Business *

Business Information

Primary Business Address *

Address Line 1

Address Line 2

City

State

Zip Code

How Long At This Address? *

Company Phone *

Company Fax *

Company Email *

Banking Information

Bank Name *

Bank Contact Phone

Bank Address

Address Line 1

Address Line 2

City

State

Zip Code

Type of Account

Account Number

Type of Second Account (*If Applicable)

Account Number 2

Insurance Information

Insurance Carrier *

Policy Number

Carrier Phone *

Insurance Address

Address Line 1

Address Line 2

City

State

Zip Code

Broker Name *

Type of Insurance

Types of Liability *

Expiration Date

Limits

Self Insured *

IF SELF INSURED, PLEASE PROVIDE LETTER ON COMPANY LETTERHEAD. THE CUSTOMER’S LIABILITY INSURANCE COMPANY CAN PROVIDE THE CERTIFICATE OF INSURANCE WITH STATEMENT OF ADDITIONAL INSURED.

Are You Tax Exempt?

Tax Exempt?

Tax Exempt Number

What Can You Tell Us About Your Companies Equipment?

Do You Own Equipment?

Please List Types of Equipment

Rent Refrigerated Trailers?

How Many?

Lease Refrigerated Trailers?

How Many?

Owner of the Trailers?

Type of Business?

Drivers Company?

How Many?

Owner Operators?

How Many?

Business / Trade References

Company Name of Reference #1

Type of Account

Reference Phone

Reference Fax

Reference Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference Email

Company Name of Reference #2

Type of Account

Reference Phone

Reference Fax

Reference Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference Email

Company Name of Reference #3

Type of Account

Reference Phone

Reference Fax

Reference Address

Address Line 1

Address Line 2

City

State

Zip Code

Reference Email

Business Contact Information

PLEASE FILL OUT YOUR NAME AND DATE TO AGREE THAT THE INFORMATION IN THIS FORM IS FACTUAL.

Your Name *

Date / Time *

DO YOU AGREE TO OUR CUSTOMER AFFIRMATION BELOW? *

Yes

CUSTOMER AFFIRMATION: I (WE) AFFIRM THAT ALL THE INFORMATION GIVEN TO COOLING CONCEPTS, LLC IS TRUE AND CORRECT. I(WE) AGREE TO NOTIFY YOU IMMEDIATELY OF ANY CHANGES IN OWNERSHIP. COOLING CONCEPTS, LLC IS AUTHORIZED TO CONDUCT CREDIT SURVEY AND TO OBTAIN CREDIT INFORMATION FROM ALL SOURCES DEEMED NECESSARY. IF CREDIT IS GRANTED TO ME, I(WE) AGREE TO PAY ALL THE INVOICES WITHIN 30 DAYS FROM DATE OF INVOICE. IF PAYMENT IS NOT MADE WITHIN 45 DAYS INVOICE IS SUBJECT TO FINANCE CHARGES. PERSONAL GUARANTEE OF BUSINESS CREDIT: FOR VALUE RECEIVED, THE UNDERSIGNED HEREBY PERSONALLY AND INDIVIDUALLY GUARANTEES PAYMENT WHEN DUE OR ALL INDEBTEDNESS NOW DUE OR WHICH MAY BECOME DUE BY APPLICANT TO COOLING CONCEPTS LLC OR ANY OF ITS AFFILIATES.

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