"*" indicates required fields Δ Customer or Company Name*Email* Mailing Address*City and State*Zip Code*Street Address*Zip Code*City and State*Business Phone*Home PhoneFaxKind of Business*IncorporatedPartnershipSole ProprietorAmount of credit requested*Federal ID#*Tax exempt #*Registered Agent*Special invoicing procedures*Principal Officers or Owners Are*Please click the + sign to add more fieldsNameSoc Sec#TitleResidence AddressPhone Add RemoveAttorney’s Name*Bank*Account Numbers*Other Accounts*Loans From*Please click the + sign to add more fieldsNameLoan Officer Add RemoveDun & Bradstreet #*Bonded* Yes No Bonding Company Name and Address*Sole Proprietor InformationEmployment*Years*Age*Spouse’s Name*First Time Owner/Operator* Yes No If no, how long as owner operator?Net Monthly Income*Credit Reference*Please click the + sign to add more fieldsNameAddress Add RemoveMortgage Company Name*Acct #*Contact*Contact Phone*Every claimed bankruptcy* Yes No If yes, what year?Every had a repossession* Yes No If yes, what year?List three relatives or friends that do not live with you*Please click the + sign to add more fieldsNameCityStatePhone #Relationship Add RemoveIn consideration of the extension of credit by Piedmont Fleet Services, Inc., the undersigned purchaser hereby agrees that the terms and conditions of all sales are as follows: 1. Terms of sale are: Net 10 from receipt of invoice. Invoices not paid within such time are past due and subject to service charge of 2 percent per month (effective rate 24 percent annum). 2. Should this account upon default, be collected by or through an attorney at law, the undersigned agrees to pay reasonable attorney’s fees in addition to the principal indebtedness and interest thereon. 3. Should purchaser be a corporation or partnership, for good and valuable consideration, including the extension of credit to the principal, the undersigned, whether officer, partner, agent, or otherwise agree that by execution hereof or behalf of the principal he or they is/ are personally liable, jointly and severally with the principal, as a guarantor(s) for the payment of all indebtedness or liabilities incurred pursuant to this agreement. Demand for payment and notice of indebtedness and default are expressly waived. In the event of default, each of the undersigned hereby assign to a seller a sufficient portion of his homestead exemption to which he may be entitled under laws of the state of his residence to pay his obligation hereunder. The terms and conditions hereof and the guarantee herein given shall continue in full force and effect until such time as the seller, Piedmont Fleet Services, Inc., shall receive from the undersigned written notice of revocation, and such revocation shall not in any way relieve the undersigned from indebtedness or liability incurred prior to the actual receipt by seller of such notice of revocation. 4. It is agreed that the sales, whether invoiced to the purchaser on his or its individual, corporate or partnership name or in any trade name or in the name of any subsidiary company or in the name of any officer or agent, shall nevertheless be an indebtedness of the purchaser hereon stated. 5. Purchaser agrees to examine all invoices and statements promptly upon receipt and to notify seller immediately of any failure of delivery, shortage, discrepancy, or error and further agrees that such invoice or statement shall be presumed correct unless he or it shall notify seller in writing of such failure of delivery, shortage, discrepancy, or error within ten (10) days of his or its receipt of such invoice or statement. 6. Seller disclaims all warranties, express or implied, to the extent permitted. 7. Purchaser agrees to immediately examine shipment or repair and agrees to notify seller promptly of any errors in shipment or repair and of any defective materials supplied. 8. Use of material shall constitute a waiver of any error in shipment, repair, or defect in material which might have been determined by a prompt and diligent inspection thereof. 9. Seller retains title and security interest in all appliances until paid for, and in all materials until such shall lose its character as personal property. I/We authorize any government agency, be it federal, state, or county to furnish information to Piedmont Fleet Services, Inc. I/We authorize Piedmont Fleet Services, Inc. to check the credit of the company and the undersigned guarantors. NOTICE: DO NOT SIGN AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS THEREOF. CORPORATION NAME*By*PresidentBy*Secretary-Treasurer CORPORATE OFFICERS MUST ALSO SIGN BELOW AS INDIVIDUAL GUARANTORS INDIVIDUALS AND PARTNERSHIPS SIGN HEREIndividual grantor*Individual grantor*