Please fill out the form below with as much information as possible and fax to

Accessories Unlimited South at  888-833-6045
Company Name:    
Billing Address:     Shipping Address:
City:     Shipping City:
State:     Shipping State:
Zip:     Shipping Zip:
Phone:      
Fax:     Email:
Contact Name:     Website Address: 
Type of Business:     Sales Tax ID:
How long have you been in business:
 Specializing in: (check all that apply) Names of employees authorized to place orders for your company 

New Bike Sales  Used Bike Sales 

First Employee:  

Accessories       Custom Bikes 

Second Employee:  

Parts                 Service

 Third Employee:  
Do you use Purchase Orders:  

Yes

No

 Fourth Employee:  
Would you like to be contacted regarding special promotions:   YesNo Fifth Employee:  
How did you hear about Accessories Unlimited:  
Payment Terms:  All new accounts shall pay by Credit Card (MC, VISA, AMEX, DISC) or COD Money Order (A UPS COD charge of $8.50 per package will be added to your order). If you wish to pay by COD Company Check, please complete the following for application.

Trade References
Company Name:     Phone:  
Address:     Open Account: Yes No
Company Name:     Phone:  
Address:     Open Account: Yes No
Company Name:     Phone:  
Address:     Open Account: Yes No
Bank Name:     Phone:  
Address:     Account Number:  

By submitting this application, I authorize Accessories Unlimited South, Inc. to make inquiries to the banking, business and/or trade references I have supplied.

Signature:

Title: Date: