(856) 697-4141 / Fax (856) 697-1058

The 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:                                             _ 

 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!