Dealer Application - Hill Country Wholesale Inc.

HILL COUNTRY WHOLESALE INC. CREDIT APPLICATION
Please complete all fields on this form, then click "Submit" below. This is a Secure Form.

Company Name:	F.E.I.N Number:
Billing Address:	Year Business Started:
City:	Business Type:	Sole Proprietor Partnership Corporation (Enter date below) Other (Specify below)
State:
Zip Code:
Shipping Address:
City:	If Other Above, Specify:
State:	Incorporation Date:
Zip Code:	Business Email Address:
Business Phone:	Store Hours:
Business Fax:	Amount of Credit Desired:

Principle Owner	Bank Name:
Address:	Bank Address:
City:	Bank City:
State:	Bank State:
Zip Code:	Bank Zip Code:
Driver's License #:	Bank Phone:
	Bus. Checking # (6 mo. min):

TRADE REFERENCES Complete the following information on three of your major open accounts or COD check approved vendors
Vendor # 1Name:	Vendor #2 Name:
City & State:	City & State:
Phone:	Phone:
Fax:	Fax:
Credit Limit:	Credit Limit:
Terms from Vendor:	Terms from Vendor:
Total Purchases:	Total Purchases:
Current Amt. Due:	Current Amt. Due:
Yrs Doing Business:	Yrs Doing Business

Vendor #3 Name	INSURANCE INFORMATION
City & State:	Name of Liability Carrier
Phone:	Policy Number:
Fax:
Credit Limit:	Comments:
Terms from Vendor:
Total Purchases:
Current Amt. Due:
Yrs Doing Business:

By hitting "Submit" below you certify that the above information is true and correct to the best of your knowledge and that you hereby authorize Hill Country to contact any firm shown on this application as a reference. You also agree that if Hill Country should sell you merchandise on open account that all sales shall be subject to the terms and conditions set forth here.