SSMB Pacific Holding Company, Inc. dba NorCal Kenworth BAY AREA 1755 Adams Avenue San Leandro, CA 94577 (510) 836-6100 MORGAN HILL 16715 Condit Road Morgan Hill, CA 95037 (408) 842-5383 SACRAMENTO 707 Display Way Sacramento, CA 95838 (916) 371-3372 ANDERSON 20769 Industry Road Anderson, CA 96007 (530) 222-1212 FILL OUT COMPLETELY AND SIGN SECOND PAGE EMAIL COMPLETED COPY TO [email protected] OR [email protected] OR FAX TO 510-836-2551 ATTN: NEW ACCOUNTS NAME OF COMPANY OR INDIVIDUAL: _______________________________________________________________________ MAILING ADDRESS: ________________________________________________________________________________________ CITY: ________________________________________________________STATE: ____________ZIP CODE: ________________ STREET ADDRESS (if different): _______________________________________________________________________________ CITY: ________________________________________________________STATE: ____________ZIP CODE: _________________ PHONE NUMBER: OFFICE: (_____) ____________________________FAX: (_____) ____________________________________ EMAIL: ____________________________________________________CELL: (_____) ___________________________________ *****All Invoices and Statements will be automatically emailed***** FILL THIS SECTION OUT IF YOU ARE A COMMERCIAL ESTABLISHMENT (CHECK ONE): INDIVIDUAL_____ PARTNERSHIP_____ LLC_____ CORPORATION_____ INCORPORATED IN THE STATE OF: _____ YEARS IN BUSINESS: _________________ IS YOUR BUSINESS LICENSE ACTIVE?: YES __________ NO ___________ HAVE YOU EVER CLAIMED BANKRUPTCY?: __________ IF YES, WHEN?: _____________________________________ PAYMENT METHOD: CHECK: ______ CREDIT CARD #: (+FEE) _____________________________ EXP: ___________ PLEASE REMIT CHECKS TO: P.O. BOX 894852 LOS ANGELES, CA 90189-4852 TRADE REFERENCE: MUST PROVIDE ALL REQUESTED INFORMATION – PLEASE, DO NOT LIST CREDIT CARDS COMPANY NAME: _________________________________________________________________________________________ ADDRESS: _______________________________________________ CITY: _________________________ ZIP: _______________ PHONE: ______________________________________________ FAX #: _______________________________________________ COMPANY NAME: _________________________________________________________________________________________ ADDRESS: _______________________________________________ CITY: _________________________ ZIP: _______________ PHONE: ______________________________________________ FAX #: _______________________________________________ COMPANY NAME: _________________________________________________________________________________________ ADDRESS: _______________________________________________ CITY: _________________________ ZIP: _______________ PHONE: ______________________________________________ FAX #: _______________________________________________ PAGE 1 OF 2 OFFICERS OF CORPORATION/LLC: PRESIDENT: ________________________________________________________________________________________________ VICE PRESIDENT: ___________________________________________________________________________________________ A/P CONTACT: _____________________________________________________________________________________________ CONTROLLER: _____________________________________________________________________________________________ RESALE? (IF YES, MUST PROVIDE ACTUAL RESALE CARD) YES: _______ NO: _______ PURCHASE ORDER REQUIRED? YES ______ NO: ______ FILL OUR THIS SECTION IF YOU ARE AN OWNER/OPERATOR OR INDIVIDUAL: NAME: _____________________________________________________________________________________________________ LAST FIRST MIDDLE INITIAL ADDRESS: _________________________________________________________________________________________________ CITY: ___________________________________________STATE: _________________________ ZIP CODE: ________________ PHONE: (_____)________________________ HOW LONG? ___________________ OWN? RENT? (CIRCLE ONE) DRIVERS LICENSE NUMBER: ____________________________________________ STATE: ____________________________ SOCIAL SECURITY NUMBER: ________________________________________________________________________________ TRUCKS HAUL FOR: ________________________________________ PHONE # OF BUSINESS: (_____)___________________ EMPLOYER’S ADDRESS: ____________________________________________________________________________________ CITY: _______________________________________ STATE: _____________________________ ZIP CODE: ________________ HOW MANY TRUCKS IN FLEET: ________________________HOW MANY TRAILERS IN FLEET: ______________________ IMPORTANT – PLEASE READ BEFORE SIGNING The above information, as well as that given on any forms provided, are for the purpose of obtaining credit and warranted to be true. The undersigned is executing this Authorization for SSMB PACIFIC HOLDING COMPANY INC to investigate the references listed and to obtain a consumer credit report on the undersigned authorized representative’s company through credit and consumer reporting agencies or other sources, in order to further evaluate the creditworthiness of such in connection with the credit evaluation process and the proposed extension of business credit to the Applicant. Nothing herein shall require the extension of credit. If credit is granted, applicant shall use such credit for commercial purposes only. SSMB may withdraw credit privileges at any time, for any reason, at its own discretion. Any credit extensions made by SSMB or its divisions to Applicant hereunder or otherwise are related. Applicant’s default under the terms of any such obligation will constitute immediate default on all obligations. If credit is withdrawn, account balances and related obligations become due immediately. If collection is made by suit or otherwise, Applicant agrees to pay all collection costs, including reasonable attorney's fee, and hereby waives all claims or rights to claim exemptions under applicable state laws. Any change in terms of this Agreement must be mutually agreed to by both parties in writing. This Agreement shall be governed by the laws of the State of California. Jurisdiction and venue shall lie in Alameda County, State of California. Applicant agrees that in any legal action brought by SSMB Pacific Holding Company and/or its affiliates to enforce its rights, applicant will pay said company’s attorney’s fees and costs of suit, in any amount to be determined by the court in which the action is brought, including any collection costs. SIGNATURE BELOW REPRESENTS AUTHORIZATION OF APPLICANT’S FINANCIAL RESPONSIBILITY, ABILITY, AND WILLINGNESS TO PAY ITS OBLIGATIONS IN ACCORDANCE WITH THE TERMS ON OUR INVOICES. ALL BALANCES PAST SIXTY DAYS WILL BE CHARGED A FINANCE CHARGE AT THE RATE OR 1.5% PER MONTH OR 18% PER ANNUM. ALL INVOICES BILLED HAVE NET 30 TERMS. ANY DISHONORED PAYMENTS ARE SUBJECT TO FEES ALLOWED BY STATE LAW. SIGNED THIS: _________________ of ______________________, 20___________. (DAY) (MONTH) _________________________________________________ PRINT NAME TITLE: ___________________________________________ (AUTHORIZED REPRESENTATIVE) _________________________________________________ SIGNATURE ***UNSIGNED OR ANY UNAUTHORIZED ALTERATION TO APPLICATION WILL NOT BE PROCESSED*** PAGE 2 OF 2
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