Rental Credit Application

"*" indicates required fields

Step 1 of 6

TRI-STATE TRAILER RENTALS, LLC

Name: Utility Tri-State, Inc.
Price range: $$$

Tulsa, OK	Oklahoma City, OK	Fort Smith, AR	N. Little Rock, AR	Texarkana, AR	Siloam Springs, AR	Carthage, MO
(918) 437-0010	(405) 440-2000	(479) 997-1111	(501) 945-0600	(870) 330-4435	(479) 373-1525	(800) 873-0010

If you have any questions about this form, please call (479) 297-6314 - Monday - Friday, 8am-5pm.

Customer Name*

First Last

Customer Dunn & Bradstreet Number

TIN or SSN*

Billing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Please enter the physical address of your company. If none exists, please use your home address instead.

Street Address Address Line 2 City State ZIP Code

Contact Name*

If you have someone you would like to assign as our contact for your company, please put their information here. Otherwise, please put your information again.

Contact Title*

Office Phone*

Cell Phone*

Email*

FAX

County*

Please enter the County your business is registered in, or located.

Description of Business*

Number of Trucks*

Please enter a number from 0 to 100000.

Please enter the number of Trucks your company has.

Number of Trailers*

Please enter a number from 0 to 100000.

Please enter the number of Trailers your company has.

SIC code

PO# Required?*

Yes

Does your business require a PO#?

Sales / Use tax exempt?*

Yes

Tax Exempt #*

Accounts Payable Contact*

E-mail Address for Accounts Payable*

Type of Business*

Partnership

Proprietorship

Corporation

Please select the type of business that best describes your company.

State of Incorporation

Please select the State in which your business is Incorporated

Type of Incorporation

Private

Public

Company in Business Since*

Company Owner Information

Owner's Name*

First Last

Owner's SSN*

Driver's License #

Please enter the owner's driver's license # here

Date of Birth*

Please enter the owner's date of birth.

Address*

Street Address Address Line 2 City State ZIP Code

Please enter the owner's address

Number of Locations*

Please enter a number from 1 to 100000.

Please enter the number of locations your business has

Company Website

Contact Name

First Last

Please enter a contact name for the company owner (such as a personal assistant)

Contact Title

The title or position of the owner's contact

Contact Phone

Contact FAX

Bank Information

Bank 1 - Name / Branch*

Please enter the name of your company's bank, and branch.

Bank 1 - Contact Name*

First Last

Please enter the name of your Bank's contact.

Bank 1 - Account Number*

Please enter the company's bank account number here

Bank 1 - Phone*

Please enter the bank's phone number

Bank 1 - FAX

Please enter the FAX number to this bank

Bank 2 - Name / Branch

Please enter the name of your company's bank, and branch.

Bank 2 - Contact Name

First Last

Please enter the name of your Bank's contact.

Bank 2 - Account Number

Please enter the company's bank account number here

Bank 2 - Phone

Please enter the bank's phone number

Bank 2 - FAX

Please enter the FAX number to this bank

Credit References

Trade Name #1*

Please enter the name of a company you have credit through.

Contact / Title

First Last Title

Please enter the Contact Name and Title for this Trade Reference.

Phone

Please enter the phone number for this Trade Reference

FAX

Please enter the fax number to this trade / credit reference.

Trade Name #2

Please enter the name of a company you have credit through.

Contact / Title

First Last Title

Please enter the Contact Name and Title for this Trade Reference.

Phone

Please enter the phone number for this Trade Reference

FAX

Please enter the fax number to this trade / credit reference.

Trade Name #3

Please enter the name of a company you have credit through.

Contact / Title

First Last Title

Please enter the Contact Name and Title for this Trade Reference.

Phone

Please enter the phone number for this Trade Reference

FAX

Please enter the fax number to this trade / credit reference.

Insurance Information

Notice: We require a valid current insurance certificate prior to any delivery or pickup of trailers, naming Tri-State Trailer Rentals, LLC as Additional Insured and Loss Payee.

Liability Coverage: Agency / Broker*

Contact*

First Last Title

Phone*

Email*

FAX

Physical Damage Coverage: Agency / Broker*

Contact*

First Last Title

Phone*

Email*

FAX

We require a valid, current insurance certificate prior to any delivery of trailers. Our insurance requirements are as follows:

General & Auto Liability coverage with a minimum of $1,000,000 limits
Physical Damage coverage for the stated value of the trailer(s)
Tri-State Trailer Rentals, LLC named Additional Insured and Loss Payee
Certificate MUST include the following statement: 30-day notice of cancellation with 10-day notice for non-payment of premium.
Certificate Holder:
Tri-State Trailer Rentals, LLC
P.O Box 52587
Tulsa, OK 74152

ADDITIONAL COMMENTS

The information given above is true and complete. Tri-State Trailer Rentals, LLC may receive from and disclose to other persons, including credit reporting agencies about Applicant and/or Business Owner's account and credit experience, and Applicant and/or Business Owner authorizes any person to release to Tri-State Trailer Rentals, LLC credit experience on Applicant and/or Business Owner made by Tri-State Trailer Rentals, LLC or any persons requested to release such information.
In the case of default in payments, Tri-State Trailer Rentals, LLC shall be entitled to exercise remedies, in addition to all other rights permitted by law:

To assess late fees and/or interest,
To submit the debt to all major credit bureaus,
The Customer agrees to pay all costs of collection, including reasonable attorney's fees

authorized representative

All invoices are due and payable on the invoice date
A 1 1/2% monthly service charge will be made on all past due invoices
All invoices are payable as rendered
All claims for adjustment must be made within 5 days from the invoice date
If invoices are not paid upon receipt of the invoice, rental account privileges will cease and we will be on C.O.D. basis and a demand for the return of the rental equipment will be issued
Tri-State Trailer Rentals, LLC has the right to limit the amount of credit extended
Signature authorizes Tri-State Trailer Rentals, LLC to verify and/or check references, bank activity and credit information.

Signature*

Name*

First Last Title

Date*

I do hereby personally guarantee this account with Tri-State Trailer Rentals, LLC (Must be Owner or Officer of the Company)

Signature*

Name*

First Last Title

Date*

TRI-STATE TRAILER RENTALS, LLC
P.O. BOX 52587
Tulsa, OK 74152

LESSEE NAME*

First Last

CONTACT NAME*

First Last

LESSEE ADDRESS

Street Address Address Line 2 City State ZIP Code

Accounts Payable Contact Name*

First Last

Accounts Payable Email*

Accounts Payable Phone*

I (we) hereby authorize Tri-State Trailer Rentals, LLC to automatically deduct the amount of my trailer rental invoices and/or other charges (including, but not limited to trailer repair invoices, toll fees, or fines incurred by the Lessee) from the bank account listed below. I understand my automatic payments will be withdrawn from my account on the due date each month or next business day if the due date falls on a weekend or holiday. This authorization will remain in effecct until Tri-State Trailer Rentals, LLC receives written notice 30 days in advance from me. Tri-State Trailer Rentals, LLC must be notified in writing at least 20 days prior to the next scheduled payment in order to stop the next automatic ACH draw. After this time, the next scheduled payment will draw regardless of a payoff received. However, Tri-State Trailer Rentals, LLC reserves the right to terminate this plan, with written notification to me, at any time.

Financial Institution Name*

Institution Phone Number*

Routing Number*

Account Number*

Type of account*

Checking

Savings

Scan and Upload*

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 256 MB, Max. files: 5.

Please scan and upload the following: Copy of Driver's License(s) Voided Check

Signature*

Date*

Name

This field is for validation purposes and should be left unchanged.

Rental Credit Application

TRI-STATE TRAILER RENTALS, LLC

Company Owner Information

Bank Information

Credit References

Insurance Information

ADDITIONAL COMMENTS

TRI-STATE TRAILER RENTALS, LLC
P.O. BOX 52587
Tulsa, OK 74152

Hours of Operation
~All Locations~

Please Select your Location or Salesperson.

Contact Finance

( or submit Credit Application )

Rental Credit Application

TRI-STATE TRAILER RENTALS, LLC

Company Owner Information

Bank Information

Credit References

Insurance Information

ADDITIONAL COMMENTS

TRI-STATE TRAILER RENTALS, LLC P.O. BOX 52587 Tulsa, OK 74152

Hours of Operation ~All Locations~

TRI-STATE TRAILER RENTALS, LLC
P.O. BOX 52587
Tulsa, OK 74152

Hours of Operation
~All Locations~