Midwest Peterbilt Group

BUSINESS INFORMATION * required fields
*Business Name (required)
Shipping Address:	Billing Address:
*Address	Address
*City	City
*State	State
*Zip	Zip
*Phone:	Phone:
Fax:	Fax:
Billing Address Same as shipping
Would you like invoices auto-emailed to you on day of purchase? Yes No
Email Address:
Type of Purchases to be made: Parts Service
Number of trucks currently operating:
Amount of Credit being requested:
Are Purchase Orders Required? Yes No
If Purchase are Restricted, list names of people who are authorized to make purchase (separate names with a comma):
Will purchases be for resale? Yes No
Will purchases be tax exempt for any other reason? Yes No
If yes for any exemption, please attach a completed State Exempt Sales Certificate with your tax exemption number.
Download Tax Exempt Forms:	Iowa Nebraska Kansas	Minnesota South Dakota Missouri

TYPE OF OWNERSHIP
Business Type Corporation Partnership Sole Proprietor
State of Incorporation:	Year:	ID#:

Name:	SSN:
Address:
City:	State: Zip:

Name:	SSN:
Address:
City:	State: Zip:

CREDIT REFERENCES **A MINIMUM OF 1 BANK REFERENCE IS REQUIRED
► Complete addresses are required ► Fax numbers or email adresses must be given for faster processing.

BANK REFERENCES:
*Name:
*Address:
*City:		State: Zip:
*Phone:		Fax:
Email:

Name:
Address:
City:		State: Zip:
Phone:		Fax:
Email:

CREDIT REFERENCES **A MINIMUM OF 4 TRADE REFERENCES ARE REQUIRED
► Complete addresses are required ► Fax numbers or email adresses must be given for faster processing.

TRADE REFERENCES:
*Name:
*Address:
*City:		State: Zip:
*Phone:		Fax:
Email:

*Name:
*Address:
*City:		State: Zip:
*Phone:		Fax:
Email:

Name:
Address:
City:		State: Zip:
Phone:		Fax:
Email:

Name:
Address:
City:		State: Zip:
Phone:		Fax:
Email:

TERMS: Net is due the 10th of the month following the month of purchase. Unpaid accounts thirty days after statement date will be charged a 1.5% (18% annual rate) finance charge per month. Finance charges must be paid to maintain an open account. In the event of default, I agree to pay collection fees and/or court costs incurred in collection of this account. A credit limit will be set based upon references. If the limit is exceded, further purchases will be cash, credit card, or guaranteed funds, unless prior arrangements are made with our Credit Department. I agree to abide by these terms.

AUTHORIZATION: The information given is true, correct and complete and is given for the purpose of obtaining credit. By the signature of the applicant you hereby authorize Sioux City Truck Sales, Inc., and or its affiliates to run a full investigation of your credit history including but not limited to, obtaining a consumer credit report to ascertain personal, partnership, or corporate credit and financial responsibility.

PERSONAL GUARANTEE: I agree to assume and pay the indebtedness of this account.

APPLICATIONS WILL NOT BE PROCESSED WITHOUT A SIGNATURE

I acknowledge this is an electronic signature and in result will be considered a signature to authorize the above.

*Signature of Owner or Corporate Officer:

Your Title:

Today's Date: 09/09/24

*Your E-Mail Address:

**Attach State Exempt Sales Certificate**

Midwest Peterbilt Group

Trucks, Parts & Service