Online Application

Fill out the account application below to join the Atlanta Wheels family. Each type of account requires different information. The form is dynamic and will add fields based the on the information you provide. You will also be required to upload supporting documentation including your Business License and a copy of your Sales & Use Tax Certificate. Credit Card accounts are also required to upload the driver's license for the card you want on file. An account representative will reach out once the account application process has started.

Type of Account

Please Check All That Apply

COD - Cash Only COD - Company Check Company Credit Card Net 30 - 15 Prox.

Download the credit card authorization form and fax to (770)955-8646

Account Information

State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Iowa Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

To Avoid a scrap tire fee of $1 per tire, please fill in your state scrap tire ID#

Billing Information

Same as Main Address

State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Iowa Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Accounts Payable

Purchase Order Required^*

Yes No

Business Information

Type of Business^*

Corporation LLC Partnership Sole Proprietorship

State of Incorporation* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Iowa Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Company's Business License^*

Copy of Sales & Use Certification^*

Copy of Driver's License^*

Add up to five(5) people that can place orders on you behalf.

Financial Statement for more than $10,000^*

Trade Reference

3 Trade References are required *

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Iowa Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Add Trade Reference

Added Trade Reference

Name	City	State	Phone	Fax

Bank Reference

Confirmation & Signature

Authorization for Release of Supplier Information^*

Yes, I authorize my Trade References listed to furnish credit information to Atlanta Wheels and Accessories in Marietta, Georgia, for the purpose of opening a charge account with their company.

Authorization for Application Dealer ^*

Must be signed by an Owner, Partner, Principal Officer, or Designed Signee.

Yes, I am authorized to complete this application and certify the above information is true and complete to the best of my knowledge. I authorize our bank and vendors to release information needed for the purpose of establishing credit worthiness. It is agreed that if credit is granted, the method of payment will be met according to the terms on the invoices. If payment is not made and our account is referred for collection, I promise to pay all collection costs, attorney's fees, and court costs incurred in order to collect any unpaid bills. I also agree to pay a late fee of one and one-half percent (1.5%) per month on all past due monies.

Signature^*

Clear

submit

Atlanta Wheels

1668 Sands Place Marietta, GA 30067

(800) 453-6247 accounting@atlantawheels.com

You must include the following in your application:

• Business License
• Copy of Sales and Use Tax Certification

We do not sell to home based businesses