Birmingham Freightliner & Western Star Parts Center

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APPLY FOR A BUSINESS PARTS ACCOUNT

Company Name:*

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Phone Number:*

Billing Address (if different from above):

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Shipping Address (if different from above):

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Desired Credit Line:*

Primary Contact Email:*

Company Is A:*

LLC

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Type of Business:*

Credit Amount Desired:*

Are You Tax Exempt?:*

Yes

Are Purchase Orders Required?:*

Yes

TRADE REFERENCES

Vendor 1:*

Contact Name 1:*

Phone Number 1:*

Email 1:*

Account Number 1:

Vendor 2:*

Contact Name 2:*

Phone Number 2:*

Email 2:*

Account Number 2:

Vendor 3:*

Contact Name 3:*

Phone Number 3:*

Email 3:*

Account Number 3:

Vendor 4:

Contact Name 4:

Phone Number 4:

Email 4:

Account Number 4:

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Women in Trucking Financing