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Application to become a KeyParts dealer

Please fill in all fields that have an * and then hit sumbit
a KeyParts representative will contact you within 72 hours

VERY IMPORTANT!!!!!

All KeyParts accounts are IP locked to prevent account sharing.
Please fill out this application from the computer you plan to place
all of your orders from or from a computer that is on your business's network.
Please follow this rule or else you will NOT be able to log into your account

Company Information
Date of Application: 08/28/2008

Company Name: *
Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Fax Number: *
Primary Contact: *
Secondary Contact: *
Primary Email Address: (Optional)
Type of Entity: *
Years in Business: *
Number of Locations: *


Owner Information

Owner's Name: *
Owner's Address: *
Owner's City: *
Owner's State: *
Owner's Zip Code: *


Banking Information

Name of Bank: *
Phone Number: *
Address: *
City *
State: *
Zip Code: *
Checking Account # *


Trade References (Please Supply Three)

Trade Reference #1
Name: *
Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Fax Number: *

Trade Reference #2
Name: *
Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Fax Number: *

Trade Reference #3
Name: *
Address: *
City: *
State: *
Zip Code: *
Phone Number: *
Fax Number: *


Agreements and Signatures

Corporate Guarantee
I hereby authorize KeyParts, Inc. to verify my references and to contact
credit reporting agencies for the purpose of obtaining credit.
I do hereby certify that the information provided herein is true
and accurate and it is understood that the creditor will rely thereon.
It is agreed that in the event that this or any account of the applicant is not paid
according to it's terms the applicant will be additionally liable for all collection
agency fees and all costs incurred in collection including, but not limited to,
attorney fees interest at the highest rate permitted by law
and the cost of disbursements if collection procedures are required.
Date: 08/28/2008
Signature: *
Title: *
Personal Guarantee
To induce creditor to grant credit to the above named company (The applicant),
I (We) do hereby personally guarantee the payment of any and all accounts of the applicant
with respect to the purchase of goods and services in the event that the applicant fails
pay said account(s) attorney fees, interest at the highest amount permitted
by law and cost of disbursement and collections.
Date: 08/28/2008
Signature: *
Title: *


Additional Notes and Instructions





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KeyParts Hoods - Give us a call at 1-800-992-1064

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(c) KeyParts Inc. 2008