MOTOR IMPACT, LLC
Off-Road Equipment & Pefprmance Products
4050 N. Palm St. Ste. 502., Fullerton, CA  / Tel:(714) 449-1333  / Fax: (714) 449-1611
Dealer / Resale & Credit Application
Company Information
Contact person		Dept.                       Position
A/P Contact Person
Business Name
Adress
Phone #	(             )	Fax # (             )
e-mail
Federal Tax ID #
Bank Information
Bank Name
Account #
Adress
Phone #		Contact Person
Trade Reference
Company Name:		Contact:
Adress
Phone:		Fax:
Company Name:		Contact:
Adress
Phone:		Fax:
I hereby certify that I am an agent for the above mentioned organization and that I am duly authorized to sign for the organization.  I understand that, if credit is granted by Motor Impact , Motor Impact shall retain title to all merchandise purchased on credit, until such merchandise has been paid in it's entirety. I the undersigned buyer, certify that all the above information is true and correct to the best of knowledge. I hereby give authorization to Motor Impact to investigate and verify business creidt, banking and trade reference.  I further understand that my organization will bear the risk of loss upon tender of delivery.
Date:         /           /	Signature:
	Print Name:
	Title: