Become a new dealer - Credit Application

Business Information

Company Name: *

Business Name: *

Ship to Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Ship to and Bill to address the same? *

No Yes

Bill to Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Ownership

Type of Business: *

Corporation Partnership Proprietorship

Principle Owner: *

First Name Last Name

Principal Owners Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Corporation Full Name: *

Corporation Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Stakeholder no.1: *

First Name Last Name

Stakeholder no.1 Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Stakeholder no.2 name: *

First Name Last Name

Stakeholder no.2 Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Purchasing Information

We will be purchasing with: *

P.O Number Contact Name Contact Number

Financial Information

Name of Bank: *

Bank Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please provide your Phone Number: *

- Area Code Phone Number

Account Number: *

Trade Information References

Please provide 3 references including account numbers. Please provide Company name, Contact at the company, phone number and account numbers below: *

Enter credit amount requested: *

Enter the value in numbers above

Notes:

Terms of application: *

By clicking here you accept that, the company/persons certifies all information entered in this form is correct and Power Plus Mobility Inc. reserves the right to cancel or withdraw credit privileges at any given time.

Email *

example@example.com

Enter the message as its shown *