CREDIT / DEALER APPLICATION Company name DBA (if different) Contact person Address
City
State
Phone
Fax
Website Address:
Email Address:
Federal tax ID or Social Security number
DUNS No
Date business established
No. of employees
Type of Account Requested: Type of Business:
Credit Card □
Corporation □
Net 30 □
Partnership □
Zip
Other Limited Liability Company □
Sole Proprietorship □
Financial Statements / PLEASE FURNISH COPY Fiscal Closing Date
Prior Year End Sales
Interim Sales No. of Months Company Officers/Partners/Owners: Name:
Title:
% Owned
Name:
Title:
% Owned
Name:
Title:
% Owned
TRADE REFERENCES
Reference #1
Name Address Phone
Reference #2
Name Address Phone
Reference #3
Name Address Phone
BANK REFERENCE Account No Phone Contact person Name of bank Address
Owner
Buyer
No. square feet store
No. square feet dedicated to accessories
What brands do you carry?
What is the major focus or marketing direction?
What makes your store the right place for our product?
I represent that the above information is true and is given to induce Spirit Leatherworks, LLC to extend credit to the applicant. My company and I authorize Spirit Leatherworks, LLC to make such credit investigation as Spirit Leatherworks, LLC sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to Spirit Leatherworks, LLC any and all information concerning the financial and credit history of my company and myself. Should your account become past due and require third party involvement, you agree to pay all collection fees, legal fees, court costs and attorney fees. PERSONAL GUARANTEE: BY MY SIGNATURE BELOW, I HAVE ACCEPTED PERSONAL LIABILITY FOR ALL AMOUNTS DUE SPIRIT LEATHERWORKS, LLC AND PROMISE TO MAKE PAYMENTS WITHIN STATED INVOICE TERMS. I have read the terms and conditions stated above and agree to all of these terms and conditions. Authorized signature Printed name
Date
Title
Social Security No.
Home Address
City
State
PLEASE FAX TO CUSTOMER SERVICE AT (541) 683-3416 or EMAIL customerservice@spiritleatherworks.com
ZIP
CREDIT CARD AUTHORIZATION FORM Account name:
I ____________________________ hereby authorize Spirit Leatherworks, LLC to charge my credit card account for shipments made on my account Mastercard
Cards Accepted:
Visa
AMEX
Card Number:
Exp. date:
Name on card:
V code:
Credit Card Billing Address:
Requested Shipping Address:
Name:
Name:
Street:
Street:
City:
City:
State:
Zip:
State:
Phone:
Phone:
Country:
Country:
Email:
Email:
Zip:
As the credit card holder, I hereby authorize the receipt of merchandise at the shipping address above.
Card holder's signature
Date
UNIFORM SALES & USE TAX CERTIFICATE—MULTIJURISDICTION The below-listed states have indicated that this form of certificate is acceptable, subject to the notes on pages 2-4. The issuer and the recipient have the responsibility of determining the proper use of this certificate under applicable laws in each state, as these may change from time to time. Spirit Leatherworks LLC Issued to Seller:________________________________________________________________________________________
100 Cap Court, Eugene, OR 97402 Address: _____________________________________________________________________________________________
I certify that: Name of Firm (Buyer): ________________________________ Address: ___________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
is engaged as a registered F Wholesaler F Retailer F Manufacturer F Seller (California) F Lessor (see notes on pages 2-4) F Other (Specify)_____________
__________________________________________________________
and is registered with the below listed states and cities within which your firm would deliver purchases to us and that any such purchases are for wholesale, resale, ingredients or components of a new product or service1 to be resold, leased, or rented in the normal course of business. We are in the business of wholesaling, retailing, manufacturing, leasing (renting) the following: Description of Business: ______________________________________________________________________________________________ General description of tangible property or taxable services to be purchased from the seller: ________________________________________ __________________________________________________________________________________________________________________ State AL1 AR AZ2 CA3 CO4 CT5 DC6 FL7 GA8 HI4,9 ID IL4,10 IA KS KY11 ME12 MD13 MI14 MN15
State Registration, Seller’s Permit, or ID Number of Purchaser ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________ ____________________________________
State MO16 NE17 NV NJ NM4,18 NC19 ND OH20 OK21 PA22 RI23 SC SD24 TN TX25 UT VT WA26 WI27
State Registration, Seller’s Permit, or ID Number of Purchaser _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________ _____________________________________
I further certify that if any property or service so purchased tax free is used or consumed by the firm as to make it subject to a Sales or use Tax we will pay the tax due directly to the proper taxing authority when state law so provides or inform the seller for added tax billing. This certificate shall be a part of each order which we may hereafter give to you, unless otherwise specified, and shall be valid until canceled by us in writing or revoked by the city or state. Under penalties of perjury, I swear or affirm that the information on this form is true and correct as to every material matter. Authorized Signature: ________________________________________________________________ (Owner, Partner or Corporate Officer)
Title: _____________________________________________________________________________ Date: _____________________________________________________________________________ Revised 10/22/2009 Page 1 of 4