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Fields

HTD Account Application

Type of Account *

Independent Tire Dealer Corporate Retail Chain New Car Dealership Used Car Dealership Government

on site mounting and balancing equipment required

Account Payment Type*

Pay on Delivery Charge Account (NET Due 10th) ACH

Charge Account Requires Signed Credit Agreement

Payment Type*

Check/Cash Credit Card (additonal 2.8% Fee per transaction)

Business Name*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Email*

Date Business Established*

https://hornsbytire.formstack.com/forms/images/2/calendar.png

Month

Day

Year

EIN*

Sales Tax Exemption Number*

Owner's Name*

First Name*

Last Name*

Drivers License*

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Signature*

[clear]

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Hornsby Tire Credit Agreement

Title of the document

Please print ,completely fill out and upload the PDF below.

Upload Completed Credit Agreement*

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Hornsby Tire Admin

All required documentation in place?*

Yes No

Missing Documentation Notes*

Primary Service Location*

Assigned Sales Rep Email*

Outside Sales Input

Customer has Retail Store Front?*

Yes No

Customer has mounting and balancing equipment?*

Yes No

Notes

Proceed with Enrollment?*

Yes No

Final Setup

HTD Account Number*

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