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Company Information:

Firm Name:

DBA:

Street Address:

Phone#:

EMAIL Address:

City:

State:

Zip Code:

Fax#:

Type of Business:

Year Started:

Federal ID#: Do you have resale exemption? [ ]Yes [ ]No

If Yes, Permit#:

Corporate Status: Check 1 (One) that applies:

[ ] Corporation, List Corporation Officers

[ ] Non-Corporation, List owners

[ ] Partnership, List Partners

President/Owner/Partner

Title:

Officer#2/Owner#2/partner#

Title:

Officer#3/Owner#3/Partner

Title:

Home Address:

Social Security#:

Phone#:

Social Security#:

Phone#:

Social Security#:

Phone#:

If Not Incorporated Please Fill The Following information:

If Partnership, Attach a Signed Resolution.

A resolution must be signed by all partners indicating they agree to an open account and that they will accept full resopnsibility for any and all charges.

Driver Licence#:

Date of Birth:

Marital Status:

Trade References: (A minimum of 3 (three) Suppliers you buy from on open account)

Reference#1:

Reference#2:

Reference#3:

Fax:

Tel:

Fax:

Tel:

Fax:

Tel:

Street:

City:

State:

Zip Code:

City:

State:

Zip Code:

City:

State:

Zip Code:

Bank Reference:

Bank Name:

Street:

City:

State:

Zip Code:

Banking Officer:

Phone#:

Account#:

Account Type (l.e Checking)

Fax#:

Real Estate Information:

Check 1(one)

Rent [ ]

Own [ ]

Street:

City:

State:

Zip Code:

Approximate Market Value

Landlord/Bank Name:

Land Lord/Bank Phone#:

Monthly Rent/Loan Payment

Landlord/Bank Street Address:

Landlord/Bank City

State:

Zip Code:

Insurance Information:

Agent Name:

Agency name:

Street Address:

Phone#:

Policy#:

City:

State:

Zip Code:

Terms

All charges are to be paid within 30 days from date of purchase. A1 1/2% per month finance charges will be assessed on all balance past due. In the event that it becomes necessary to initiate legal action to collect funds due , it is agreed that Galpin Motors, Inc., shall be entitled to recovery of attorney's fee, court costs, and any other costs or fees allowed by law. WRITTEN PURCHASE ORDERS ARE REQUIRED ON ALL PURCHASES(unless other written arrangements are made).

Galpin Motors, Inc. is authorized to verify and all sources associated with the above to substantiate credit information as relates to this matter.

GALPIN MOTORS, INC.
1763 N. Ivar Avenue, Hollywood, CA 90028
(323) 957-3333 Phone * (323) 856-6790 Fax

CREDIT CARD AUTHORIZATION REQUEST

Name of Card Holder :
Address:
Business Name:
Office Phone:	Home Phone:
Credit Card & Bank:
Credit Card No#:	Expire Date:
Social Security No#:

I hereby authorize Galpin Motors, Inc. Rental Car Division to process the above credit card for full payment of all rental charges incured by me and/or the names listed below. It is also agreed that I may pay cash or check upon return of any vehicle (s) if I so choose. Substitution of payment in lieu of processing my credit card must be done upon return of any rented vehicles.

When signed, this document will serve as "Signature on File" for all rental agreements in my name and/or in the name of my company and/or in the name of individuals listed below as authorized to sign.

This agreement may be terminated by either party within 30 days written notice or upon the expiration date of the credit card whichever occurs first. Any outstanding balance owed can, and will, be charged to my credit card. In the event no further charges can be processed on my credit card, for any reason, I agree to be personally responsible to pay those charges to Galpin Motors, Inc. upon demand.

	Signature of Cardholder		Date

	Driver's Licence No.		State & Expiration Date


Individuals authorised to sign on above Credit Card
Name:	DL. No.
Name:	DL. No.
Name of the Company:

PERSONAL GUARANTEE

In consideration of the arrangements between Galpin Motors, Inc.
	and

	Name of the Company

I understand and agree to be personally responsible for any and all financial obligations of the above named business and/or individual. I also accept responsibility for all terms and conditions set forth between Galpin Motors, Inc. and the above referenced business or individual. This includes but not limited to all terms and conditions as set forth in any and all RENTAL AGREEMENTS and other INVOICES.

I agree that Galpin Motors, Inc. may verify information presented with any credit bureau or other sources available.

Name:
Address:
City:	State:	Zip:
Home Phone No.:	Business Phone No.:
Social Security No.:
Driver Licence No#:	State:	Exp:
Date of Birth:

Signature

Date

1763 N. Ivar Avenue, Hollywood, CA 90028 Phone: (323) 957 3333 Fax: (323) 856 6790
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15505 Roscoe Blvd. North Hills, CA 91343.

Galpin Ford

Sales Phone: (800) 256-7137
Service Phone: (800) 256-6219

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(Signature of Corporate officer)

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