Test

JUSTIN COULTER
Director of Sales
502.552.1683‬
[email protected]

Business Name

Primary Contact Name

First Last

Email(Required)

Email me when the shocks are for sale.

Phone

Estimated Order Quantity(Required)

Please enter a number greater than or equal to 1.

Your Business Relationship Manager(Required)

I agree to be contacted.

By clicking, I agree to be contacted in relation to sales promotions and campaigns. I consent to SuperSprings International (SSI) email communication and understand that SSI will not sell my information for outsourced marketing.

Name

First Last

Email(Required)

Email me when the shocks are for sale.

Text/SMS

Please also send me an SMS text message

I agree to be contacted.

By clicking, I agree to be contacted in relation to sales promotions and campaigns. I consent to SuperSprings International (SSI) SMS and email communication and undertsand that SSI will not sell my information for outsourced marketing.

Name

First Last

Email(Required)

Email me when the shocks are for sale.

Text/SMS

Please also send me an SMS text message

I agree to be contacted.

By clicking, I agree to be contacted in relation to sales promotions and campaigns. I consent to SuperSprings International (SSI) SMS and email communication and undertsand that SSI will not sell my information for outsourced marketing.

"*" indicates required fields

Step 1 of 4

Your Information

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Purchase Information

Part Number(s) Purchased*

Date Purchased*

Where did you make your purchase?*

How was the vehicle being used when the failure occurred?*

Who installed the product?*

Installation Invoice Upload (Optional)

Max. file size: 20 MB.

Vehicle Information

Year*

Make*

Model*

Drivetrain*

Is the vehicle on which the product is installed used for commercial purposes?

Yes

No

What is the defect in the product?*

What is your preferred contact method?*

Phone

Email

Do you own the vehicle in which the product is installed?*

Yes

No

Has the product ever been in stalled on another vehicle?*

Yes

No

Upload image of the damaged item(s)*

Max. file size: 20 MB.

Upload your proof of purchase*

Max. file size: 20 MB.

JUSTIN TEVIS
Director of Finance
805.696.5521
[email protected]

Name(Required)

First Last

Company Name(Required)

Position with Company(Required)

Email(Required)

Acknowledgement(Required)

I agree to the Supplier Terms and Conditions

GERRY LAMBERTI
Chairman & CEO
805.453.2726
[email protected]

TOM BATEMAN
Director of Marketing
208.512.0855
[email protected]

JENI CHEN
Director of Operations
805.698.1608
[email protected]

ADAM WEISNER
President
208.449.9506
[email protected]

Thank you for leaving a review for the . We’re excited to be part of making your journey better.

Name*
First Last
Company Name
Title
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone

Customer Credit Application

Please provide company information, bank reference information, and four trade references.

Step 1 of 6

Company Information
Company Name*
Doing Business As (DBA)
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Contact*
First Last
Phone
Email
Primary Contact Position/Title*
Shipping Address
If different from Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Type of Business*
- Proprietorship
- Partnership
- Corporation
Federal Tax Payer ID No.
Year Business Established*
Please enter a number from 0000 to 9999.
Resale No.
Attachments
Without a copy of your Tax Exemption Certificate your Customer Credit Application cannot be processed. You must attach a copy to continue with this form. Please attach below as a jpg, pdf, tif, png, or similar file type.
Tax Exemption Certificate
Maximum file(s) size = 20MB.
Accepted file types: jpg, txt, gif, png, pdf, tif, ai, psd, zip, eps, doc, docx, Max. file size: 20 MB.
Do you have a Resale Certificate for your state?*
- Yes
- No
- Not applicable
Resale Certificate*
Please follow all rules according to your state when submitting valid Resale Certificates. Maximum file(s) size = 20MB.
Accepted file types: jpg, txt, gif, png, pdf, tif, ai, psd, zip, eps, doc, docx, Max. file size: 20 MB.

Save and Continue Later

Bank Reference
Bank Name*
Account No.*
Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Contact
First Last
Bank Phone*
Bank Fax*

Save and Continue Later

Trade Reference #1
Reference #1 Company Name*
Reference #1 Phone*
Reference #1 Email*
Reference #1 Fax
Reference #1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Trade Reference #2
Reference #2 Company Name*
Reference #2 Phone*
Reference #2 Email*
Reference #2 Fax
Reference #2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Trade Reference #3
Reference #3 Company Name*
Reference #3 Phone*
Reference #3 Email*
Reference #3 Fax
Reference #3 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Trade Reference #4
Reference #4 Company Name*
Reference #4 Phone*
Reference #4 Email*
Reference #4 Fax
Reference #4 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Credit Reference

Credit Referral
Please complete this form so we may determine the credit worthiness of this applicant.
Your Company Information
Company Name:*
Name*
First Middle Last
Referral information
Sold Since:
High Credit:
Date of Last Sale:

Example: 01/01/2019
A/R Balance:
A/R Info:
Current
1 of 4
1-30 days
2 of 4
31-60 days
3 of 4
Over 90
4 of 4
Total A/R
Sum of the last 4 questions
Terms
Percent:
Please enter a number from 0 to 100.
Days:
Net:
Discount:
Average Days to Pay:
Prompt:
Slow:
NSF Checks:
Comments
Add additional comments here...