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Tire Clean Ups
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Home
Request Service
Containers
Tire Clean Ups
About
Contact
Request Service Application
Firm Name
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Phone (XXX-XXX-XXXX)
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Email
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Fax
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Service Address
Service Address
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City/State
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Zip
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Billing Address if different that Service Address
Billing Address
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City/State
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Zip
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Company Information
Years Established
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Your Company is
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Corporation
Partnership
Sole Prep
Other
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Federal ID or SS#
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Have you ever filed bankruptcy?
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Yes
No
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Name & Branch of Bank
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Checking Account #
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Savings Account #
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Do you own the business property?
(*)
Yes
No
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If a corporation, do stockholders own property?
Yes
No
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Current Credit References - Please List 3
Name
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Address
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City/State/Zip
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Phone (XXX-XXX-XXXX)
(*)
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Name
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Address
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City/State/Zip
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Phone (XXX-XXX-XXXX)
(*)
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Name
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Address
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City/State/Zip
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Phone (XXX-XXX-XXXX)
(*)
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We have available credit card or bank card Auto Pay that is processed on the 5th of each month, if you are interested check below.
Auto Payment
(*)
Yes, I would like to signup for Auto Pay
No thanks
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Terms of Service
TERMS:
NET 30 DAYS. ACCOUNTS NOT PAID BY THE LAST BUSINESS DAY OF THE MONTH FOLLOWING STATEMENT DATE ARE DELINQUENT AND SUBJECT TO A LATE CHARGE OF 1.5% OF THE DELINQUENT AMOUNT PER STATEMENT PERIOD. THE CUSTOMER IS RESPONSIBLE FOR ANY DAMAGE TO SHAMROCK TIRE RECYCLING'S PROPERTY. THE CUSTOMER IS ALSO RESPONSIBLE FOR THE CONTENTS OF THE CONTAINER. SHAMROCK TIRE RECYCLING IS AUTHORIZED TO CONTACT ANY REFERENCES LISTED ABOVE.
ALL CONTAINER ACCTS 60 DAYS PAST DUE, THE CONTENTS WILL BE LIQUIDATED & ALL COST INCURRED WILL BE PAID BY THE CUSTOMER.
CERTIFICATION:
CERTIFY THAT THE INFORMATION GIVEN ABOVE IS CORRECT. I HAVE READ AND UNDERSTAND THE
TERMS
AND
RATES
AS STATED AND AGREE TO PAY THE ACCOUNT IN THE ABOVE NAME WITHIN THESE TERMS. IN THE EVENT I FAIL TO PAY, AND IT BECOMES NECESSARY TO PLACE THIS ACCOUNT IN THE HANDS OF AN ATTORNEY FOR COLLECTION, I AGREE TO PAY A REASONABLE ATTORNEY FEE FOR ITS COLLECTION.
Terms Agreement
(*)
I have read and agree with the terms above.
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GUARANTEE:
I HEREBY GUARANTEE TO AMERICAN REFUSE THE PAYMENT OF ANY AND ALL DEBTS OF THE ABOVE COMPANY. THIS IS A CONTINUING GUARANTEE AND SHALL REMAIN IN FORCE UNTIL REVOKED BY THE GUARANTOR GIVING WRITTEN NOTICE TO SHAMROCK TIRE RECYCLING.
Guarantor Full Name
(*)
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(*)
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Submit
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