Credit Application

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Please fill in the form below and a representative will contact you after it has been reviewed.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Application Type*

Which company are you apply credit for?*

Omaha Track Sales Contact Name:*

Requested Monthly Credit Limit:

Name*

First Last

Company Name*

DBA

Country

Street Address

Street Address Line 2

City

State/ Province

Zip/Postal Code

Phone Number*

Fax Number

Email*

Accounts Payable Email Address*

Company Web Address

Accounts Payable Contact Name*

Accounts Payable Contact Phone*

Business Type*

LLC*

Federal ID Number*

Are you sales tax exempt?*

Sales Tax Resale Number*

State

Please attach exemption certificate

Max. file size: 32 MB.

P.O. Required

Total Years in Business*

How many years in business at current location?*

Have you ever filed bankruptcy?*

if yes, when?*

Have you received credit from this company before?*

Under what name?

Dun & Bradstreet Number

Bank Reference:

Bank Reference*

Attachment for Bank Reference*

Max. file size: 32 MB.

Name of Bank*

Country

Street Address

Street Address Line 2

City

State/Province

Zip/Postal Code

Phone #*

Email Address

Fax #

Account #*

Account #

Company Credit References (Do not list credit card)

Company Credit References*

Attachment for Credit Letter*

Max. file size: 32 MB.

Company 1*

Country

Street Address

Street Address Line 2

City

State/Province

Zip/Postal Code

Phone #*

Email Address*

Fax #

Company 2*

Country

Street Address

Street Address Line 2

City

State/Province

Zip/Postal Code

Phone #*

Email Address*

Fax #

Company 3*

Country

Street Address

Street Address Line 2

City

State/Province

Zip/Postal Code

Phone #*

Email Address*

Fax #

Terms and Conditions:

1. Purchaser will promptly notify Omaha Track of any change in the undersigned's legal status.

2. Purchaser agrees to pay invoices due within the terms stated on the invoice. If invoices are not paid within terms extended, account will be placed on a cash basis until account is paid in full.

3. Purchaser agrees to pay costs of collection of any unpaid account, including reasonable Attorney’s fees and costs incurred to effect collection, with or without suit, including preparation, filing and foreclosure of any liens.

4. A minimum interest charge of 1.5% per month (18% per annum) will be assessed on all past due invoices.

I hereby agree to abide by foregoing terms that the above information is true and complete. Omaha Track is authorized to contact credit references provided and to obtain any further credit information needed to substantiate credit requested.

Name*

First Last

Title*

Signature*

Date*

CORPORATION

If you are a corporation the application must be signed by an officer of the corporation. He/She must sign on all for lines. (Company and individual)

Company Name:*

Signed by:*

First Last

Signature*

Title*

Date*

The Finance Department Requires 48 Hours to Process This Application.
Failure To Provide Complete Information May Delay Credit Approval.

Additional Comments

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