(OLD) Customer Registration Form

Counselman Automotive Recycling Customer Account Application

Please fill in the form below
Name of Business *
DBA (if different)
Mailing Address *

Street Address

Street Address Line 2

City State

Zip Code
Physical Address (if different)

Street Address

Street Address Line 2

City State

Zip Code
Office Number *

Area Code Phone Number
Cell Number (if different)

Area Code Phone Number
Fax

Area Code Phone Number
Contact Name *

First Name Last Name
Year Opened
Federal ID#
If no Federal ID# available, please add SSN here
E-mail *
Are Purchases Tax Exempt? *

Yes No
State Sales Tax #
Please Attach A Copy Of Your Current Sales Tax Certificate

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Would you like to open a Credit Account? *

Yes No
Personal Guaranty

For good and valuable consideration, including the extension of credit to Credit Applicant, do hereby unconditionally guarantee and promise to pay in full on demand any and all obligations of Credit Applicant to Counselman Automotive Recycling, LLC without regard for any claim of setoff, counterclaim or defense. I hereby waive notice of sales to Credit Applicant, and of the terms thereof, and of non-payment or other default or dispute with Credit Applicant. I hereby waive any right to a jury trial and consent to all renewals and modifications of terms of sale or credit. This is a continuing and irrevocable guaranty that shall remain effective and enforceable regardless of any change in the form, composition, nature, personnel or location of Credit Applicant and I hereby subordinate any indebtedness of Credit Applicant to me to that of Credit Applicant to Counselman Automotive Recycling, LLC. I recognize that my individual credit history may be a necessary factor in the evaluation of this Guaranty and hereby consent to and authorize the use of a consumer credit report on me by Counselman Automotive Recycling, LLC, as a business credit grantor, from time to time as needed in the ongoing credit evaluation process. In the event Counselman Automotive Recycling, LLC should commence any action or actions, or otherwise seek to enforce this Guaranty against me, I agree to pay reasonable attorney(s) fees, court costs and other expenses incurred by Counselman Automotive Recycling, LLC in said action, whether or not suit is filed. I agree that a facsimile copy of this Guaranty shall be considered an original and admissible in a court of law to the same extent as the original document. This Guaranty shall inure to the benefit of Counselman Automotive Recycling, LLC and its successors and assigns and shall bind my heirs, executors, personal representatives, administrators and other successors.
Desired Credit Limit *
All Credit Accounts are subject to an 18% interest charge on all outstanding balances over 60 days.
Bank References
Bank Name *
Bank Contact *
Phone *
Account # *
Credit Account References
Company *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Company *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
Company *
Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State

Zip Code
I/we authorize all of the above named persons/companies to release to Counselman Automotive Recycling, LLC or its representatives such information regarding my/our financial condition. By signing below I state that I have read, understand and agree to the Personal Guaranty, and that I have the authority to represent the above named Credit Applicant.
Signature *

Clear
Print Name *
Title *
Date *

Month Day Year
SSN# *
Home Address *

Street Address

Street Address Line 2

City State

Zip Code
Should be Empty:

Counselman Automotive Recycling Customer Account Application

Bank References

Credit Account References