COMPANY NAME: _____________________________________________________________ BILLING ADDRESS: ____________________________________________________________ CITY: ________________________ STATE: ___________________ ZIP CODE: ___________ TELEPHONE NUMBER: _______________________ FAX NUMBER: ____________________ SHIPPING ADDRESS: __________________________________________________________ CITY: ________________________ STATE: ___________________ ZIP CODE: ___________ FEDERAL TAX ID: _____________________________________________________________ SALES TAX EXEMPT NUMBER: __________________________________________________ YEARS IN BUSINESS: ________________ BUSINESS TYPE: __________________________ EMAIL ADDRESS: ______________________________________________________________ WEBSITE: _____________________________________________________________________ NAME OF OWNERS/PARTNERS/PRINCIPLES: OWNER/PRESIDENT: __________________________________________________________ PARTNER/VICE PRESIDENT: ____________________________________________________ TREASUSER/BOOKKEEPER: ____________________________________________________ AMOUNT OF CREDIT REQUESTED: ______________________________________________ BANK INFORMATION: Bank Name: ____________________________________________________________ Address: ______________________________________________________________ Phone Number: _________________________________________________________ Account Number: _______________________________________________________

WEST COAST PARTS DISTRIBUTING14465 Griffith St.San Leandro, CA 94577Phone: 888-833-0306Fax: 888-419-1545

TRADE REFERENCES:

1. Name: _____________________________________________________________ Address: ___________________________________________________________ Phone Number: ______________________ Fax Number: ____________________

2. Name: ______________________________________________________________

Address: ___________________________________________________________ Phone Number: ______________________ Fax Number: ____________________

3. Name: _____________________________________________________________ Address: ___________________________________________________________ Phone Number: ______________________ Fax Number: ____________________

4. Name: _____________________________________________________________ Address: ___________________________________________________________ Phone Number: ______________________ Fax Number: ____________________

CREDIT CARD INFORMATION: Credit Card Number:______________________________________________________________ Expiration Date:_________________ 3-Digit Code:_____________________ Name on Credit Card:______________________________________________________________ Address: _____________________________________________ Zip Code:__________________ Signature Authorizing Use of Credit Card:_____________________________________________ As stated, the credit card will not be used unless payment to the account is late.

Our open account terms are: Pay the full amount from the statement for the previous month’s purchases. We must receive payment by the 15th of the following month to keep the open account in good standing. __________________________________ Authorized Signature Title of Signer: ____________________________________ Date: _______________________ __________________________________ Authorized Signature Title of Signer: ____________________________________ Date: _______________________ Applicant’s signature attests financial responsibility, ability and willingness to pay our invoices. Upon completion and return of this application, I will contact your trade references for their recommendations. West Coast Parts places much value on timely payments to the account. Any additional information you can provide to speed the process will be appreciated. Thank you and I look forward to working with you. Should you have any question, don’t hesitate to contact me. Sincerely, Sam Baltz Parts Manager