Sole Proprietorship Partnership CorporationThe undersigned, __________________________________________ is applying for credit with Gen Serv Maintenance Supply, and certify that all statements contained are true and correct. The applicant agrees that any credit granted shall be paid promptly in accordance with credit grantor terms and agreements. Applicant also agrees, in the event of default, to pay reasonable collection charges, attorney fees and court costs where applicable.
Company Information
Name of Company:
Assumed Name of Company:
Shipping Address:
City: State: Zip Code:
Telephone: (________) Fax: (________)
Contact Person: Title:
E-Mail Address: Web Address:
If Billing Address is different from above, please fill in the following:
Name of Company: ____
Billing Address:
City: State: Zip Code:
Telephone: (________) Fax: (________)
Contact Person: Title: _
E-Mail Address: Web Address:
Detailed Company Information
Federal Tax ID No. Or Social Security No.:
Type of Business: No. of Employees:
Date Business Established: Amount of Credit Requested:
Types of Products Your Company Will Purchase:
Check Appropriate Box and Fill in Requested Information:
Sole Proprietorship Partnership Corporation
Sales Tax Exemption Certificate Attached Charge Applicable Tax
Has your company ever had credit with us before? Yes No
If yes, under what name?
Do you require a Purchase Order? Yes No
Names of Authorized Purchasers:
How did you hear about our company?
Phone Book Web Site Brochure/Pamphlet Salesman Contact Other
Trade References (Fax numbers are required)
Company: Contact/Title:
Address,City,State,Zip:
Telephone: (________) Fax: (________)
Company: Contact/Title:
Address,City,State,Zip:
Telephone: (________) Fax: (________)
Company: Contact/Title:
Address,City,State,Zip:
Telephone: (________) Fax: (________)
Bank References
Name: Address:
Type of Account: Account Number:
Telephone: (________) Fax: (________)
Contact: Title:
Name: Address:
Type of Account: Account Number:
Telephone: (________) Fax: (________)
Contact: Title:
I, , authorize Gen Serv Maintenance Supply to make such credit investigations as required including contacting the above trade references and banks and obtaining credit reports. I also authorize all trade references, banks and credit reporting agencies to disclose to Gen Serv Maintenance Supply all pertinent information concerning the financial and credit history of _____________________________.
Name of Company:
Authorized Signature: Print:
Title: Date:
FOR OFFICE USE ONLY (Please do not write below this line)
Checked Trade Reference Yes No Checked Bank Reference Yes No
Good Fair Poor Good Fair Poor
Approved Credit Limit $
Denied Give Reason:_ ________________________________________________________
Terms: _____________ Sales Rep: ____________
Approval Letter Sent:
Authorized Signature:
THANK YOU FOR APPLYING FOR CREDIT WITH OUR COMPANY,
YOU WILL BE HEARING FROM US VERY SOON!