SuperCoils

Company Name*
Company Website
Current SSI Contact*
How did you hear about us?*
Accounts Payable Contact
Person responsible for Accounts Payable
Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Person responsible for Accounts Payable Statements*
- Same as Accounts Payable
- Someone else
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Purchasing Agent*
- Same as Accounts Payable
- Same as Accounts Payable Statements
- Someone else
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
To whom should we send purchasing/shipping notifications?*
Select all that apply
- Same as Accounts Payable
- Same as Accounts Payable Statements
- Purchasing Agent
To what address should we ship product?*
- Accounts payable contact
- Accounts payable statements contact
- Purchasing agent contact
- New address
Name
First Last
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Add a note for the team:
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JUSTIN COULTER
Director of Sales
502.552.1683‬
[email protected]

"*" indicates required fields

Step 1 of 4

Your Information

Please provide a clear image of the barcoding label from the box in which the product was shipped. This will help expedite your request. Warranty requests without the label information may be delayed.

Name*

First Last

Address*

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

Phone*

Email*

JUSTIN TEVIS
Director of Finance
805.696.5521
[email protected]

Name(Required)

First Last

Company Name(Required)

Position with Company(Required)

Email(Required)

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
How did you hear about the magazine?

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.

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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
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Your Items

Accounts Payable Contact

Accounts Payable Contact

Your Information

Purchase Information

Vehicle Information

Company Information

Attachments

Bank Reference

Trade Reference #1

Trade Reference #2

Trade Reference #3

Trade Reference #4

Credit Referral

Your Company Information

Referral information

A/R Info:

Terms

Comments

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SuperCoils