ONLINE APPLICATION for CREDIT with BROWN TRANSMISSION

First Name: Last Name :
Phone: Email:

Billing Information
Address 1:
Address 2:
City:
State: Zip:

Shipping Information
Address 1:
Address 2:
City:
State: Zip:

About your Business
Type of Business:
  Partnership Corporation Individual
Owner/Officer: Title:
Referred By:

Required Information *
* If yearly sales are to be under $1,500, then credit card information is required:
Credit Card Company:
Card #: Exp. Date:
Secondary Company:
Card #: Exp. Date:
SSN:
Tax Exempt **
   
  If yes, mail signed tax exempt form
 

Existing Accounts
Please furnish three suppliers with whom you have an open account:
1. Name:
Phone:
  Address:
City/State/Zip:
2. Name:
Phone:
  Address:
City/State/Zip:
3. Name:
Phone:
  Address:
City/State/Zip:

References (Required)
Bank:
Account: Phone:

Detailed Ship To Information
1. Company Location
  Address:
City/State/Zip:
  Other Info :
       
2. Company Location
  Address:
City/State/Zip:
  Other Info :
       
3. Company Location
  Address:
City/State/Zip:
  Other Info :
       
  Key Contacts
  Name:
  Title:
Phone:
  Name:
  Title:
Phone:
  Name:
  Title:
Phone:
 
  After Hours Deliveries
  Receiving (Phone):
  Maintenance (Phone):
  Engineering (Phone):
 
 
By submitting your credit application with Brown, you indicate that you have read and agree to the Terms and Conditions.
       
 
** TAX EXEMPT
Mail completed tax exempt form to:
Brown Transmission & Bearing Co.
171 Greenfield Road
Lancaster, PA 17601
 
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