Credit App

Establish Credit with Covington Heavy Duty Parts, Inc.

You may either download and fill out our credit form and mail or fax to us OR you can make a credit request using the online form below.

Download and fill out form.

We will respond to your request in a timely manner. Thank You for your business consideration.


Your Name (required)

Your Email (required)

Company Name (required)

Branch Name if applicable:

 Incorporated Partnership Individual

Billing Address (Street or PO, city, ST Zip): (required)

County:

County Tax Rate:

Federal Tax ID: (required)

Sales Tax #:

*If you are a tax exempt company please provide your tax number and a copy of your sales tax certificate or sales tax will be charged.

Type of Business:

How long in business:

Number of Vehicles Operated:
Trucks:
Trailers:

Office Phone:

Shop Phone:

Fax:

Purchase Order # Required?  Yes No

Person(s) Authorized to Purchase:

Contact information for Accounts Payable (Name, Phone, email, etc):

List Corporate Officers/Individual Owners/Partners (required)
*Include Name, Title, Home Address, Phone, SS#

Trade Credit References (required)
*List 3 - Do not list bank or credit card company. Please include Name, Address, Phone (required)

Bank References (required)
*Name, Address, Phone, Officer Name

Are you listed with Dunn & Bradstreet?  Yes No

If so, please provide #:

Have you or the company listed on this application ever filed Bankruptcy?  Yes No

Explain:

IF you would like your statements emailed please provide address:

If you would like your invoice at Point of Sale emailed please provide address:

READ AND ACCEPT TERMS & CONDITIONS:

 Accept

All fields marked "required" must be filled out in order for the form to submit properly.