Account Sign-Up

Fill in the form below to sign up for an account with DTI.
Name of Company:
Type of Business:
Street Address:
City/State/Zip:
Country:
Phone Number:
Fax Number:
	This is the only Bill To/Ship To location.
	There are other Bill To/Ship To locations. (Fill in at the bottom of this form.)
Type of Account:	COD
	Credit Card
	Prepay
	Open Account (Also, complete a credit application.)

Principles or Officers
Name:
Address:
City/State:
Home Phone:

Name:
Address:
City/State:
Home Phone:

Name:
Address:
City/State:
Home Phone:

Trade References
Company Name:
Phone:
Fax:
Account #:

Company Name:
Phone:
Fax:
Account #:

Company Name:
Phone:
Fax:
Account #:

TAX CERTIFICATE Fax a copy of your State Tax Certificate along with this form to 1-800-825-0919 or mail it to the following address: DTI RV Parts & Appliances, 52649 Leer Court, Elkhart, IN 46514 Upon submitting this completed form and a copy of your state tax certificate an account will be established for your company by DTI RV Parts & Appliances. To establish an account with open terms, a credit application must also be submitted and approved.

Additional Ship To Locations
Name of Company:
Phone:
Fax:
Type of Business:
Address:
City/State/Zip:
Contact:
Title:

Name of Company:
Phone:
Fax:
Type of Business:
Address:
City/State/Zip:
Contact:
Title:

Name of Company:
Phone:
Fax:
Type of Business:
Address:
City/State/Zip:
Contact:
Title:

Applicant's Certification I agree to the credit terms specified in this application and should action be required to enforce payment of any past due account, I agree to pay all costs, including but not limited to court costs, attorney's fees and collection agency charges that may be incurred. The information I have provided in this application is true and correct to the best of my knowledge and I authorize you to contact the references that I have listed in order to determine my creditworthiness. Note: If dealer is a corporation or partnership, this must be signed by a corporate officer or a general partner.
Signature:
Date:

DTI RV Parts & Appliances
52649 Leer Court · Elkhart, Indiana 46514
Toll Free: 800-289-0919 · Fax: 800-825-0919 · Email: info@dtiparts.com