Online Credit Application

CLICK HERE TO DOWNLOAD OUR CREDIT APPLICATION

Or fill out the Online Credit Application.

• Firm Name*
• Billing Address
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
  If billing address is the same as shipping address, leave blank.
• Shipping Address*
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Requested By
•    
•    
• Phone Number*
• Fax Number
• Email*
  Enter Email Confirm Email
• Website
  Ex.: www.yourwebsite.com
• Years in business
• Business Type*
  • Corporation
  • Partnership
  • Proprietorship
•    
•    
•    

• CONTACT PERSONS:

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• Individual Contact (Shop)
• Accounts Payable
• Type Of Business
  Example: Garage, Service Center, Fleet, Independent Contractor.
• Number of employees
• Credit Line Desired $
• P.O. Required?*
  • Yes
  • No
• Exemption or Resale Certificate Attached. **See Below For Details
  • Yes
  • No
• DUNS #
• Federal Tax ID No. (Corporation)
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• Social Security No. (Partnership or Individual)
•    
• Does this Business have more then one branch?
  • Yes
  • No
• If Yes, List Addresses
  Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
•        
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• LIST OF OWNERS/OFFICERS:

  Name & Title	Addresss	City, State, Zip

  Please list owner or at least two officers.
•    
•    
• TRADE REFERENCES

  Name	Address	Phone	Fax

  Please list a minimum of three trade references.
•    
• Republic Sales Representative:
•    
• Printed Name
• Title
• Date
•    
•    
• Acknowledgment*
  • I understand that submitting this form authorizes Republic Diesel to proceed with processing this credit application.
• CAPTCHA
• Name
  This field is for validation purposes and should be left unchanged.

Unless otherwise amended on the Invoice, CREDIT TERMS: NET 30 DAYS

All invoices are due and payable per the terms stated on the invoice. A service charge will be assessed on all past due invoices at the rate of 1 1/2% (one and one-half percent) per month (18% per annum). If payments are not received in accordance with our terms, your account will automatically revert to COD status. The undersigned agrees to these terms and to pay any and all costs of collection for past due amounts.

THIS APPLICATION IS MADE WITH THE UNDERSTANDING AND AGREEMENT THAT ALL CHARGES FOR PARTS AND SERVICE WORK ARE DUE AND PAYABLE PER THE TERMS STATED ON THE INVOICE.

**Sales Tax Exemption Certificates should be submitted to PO Box 35650 Louisville, KY 40232, Or Fax To:  502-561-2347, Or Email to: [email protected]

If you have any questions about the Online Credit Application call our Credit Department at (502)561-2200 or email [email protected] and we will be able to answer your questions.