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APPLICATION FOR CREDIT |
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*Please print this form and then fill it out, then fax it to us! We must have a signature* |
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BUSINESS NAME _________________________________________________________________________________________ STREET ADDRESS _________________________________________________________________________________________ P.O. BOX ______ P.O. BOX ZIP ______ EMAIL _____________ WEBSITE ADDRESS______________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ TYPE OF BUSINESS _____________________________ DATE ESTABLISHED ________________ |
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OWNERSHIP - CHECK ONE BELOW |
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| THIS BUSINESS IS A CORPORATION (IF CHECKED, GIVE NAMES OF CORPORATE OFFICERS) | |
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NAME _______________________ TITLE ________________________________ NAME _______________________ TITLE ________________________________ FED ID#______________________ |
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| THIS BUSINESS IS A SOLE PROPRIETORSHIP (IF CHECKED, FILL OUT THE INFORMATION BELOW) | |
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OWNERS NAME __________________________ SSN _____________________________ STREET ADDRESS ____________________________________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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| THIS BUSINESS IS A PARTNERSHIP (IF CHECKED, FILL OUT THE INFORMATION BELOW) | |
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OWNERS NAME __________________________ SSN _____________________________ STREET ADDRESS ____________________________________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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OWNERS NAME __________________________ SSN _____________________________ STREET ADDRESS ____________________________________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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IF BILLS ARE PAID BY A PARENT COMPANY, FILL IN THE INFORMATION BELOW |
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PARENT COMPANY______________________________________________________________ STREET ADDRESS ______________________________________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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BANK REFERENCES |
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SAVINGS NAME _______________________ ACCT# ____________________________ CHECKING BRANCH ________________________ LOAN STREET ADDRESS _____________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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SAVINGS NAME _______________________ ACCT# ____________________________ CHECKING BRANCH ________________________ LOAN STREET ADDRESS _____________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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| COMMERCIAL TRADE REFERENCES: GIVE ONLY NAMES OF THOSE YOU BUY FROM ON OPEN ACCOUNT. REFERENCES WILL NOT BE CONSIDERED VALID UNLESS FULL NAMES AND ADDRESSES ARE INCLUDED. PLEASE LIST A MINIMUM OF THREE. | |
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1. NAME __________________________________ STREET ADDRESS __________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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2. NAME __________________________________ STREET ADDRESS __________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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3. NAME __________________________________ STREET ADDRESS __________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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4. NAME __________________________________ STREET ADDRESS __________________________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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click here for PERSONAL GUARANTEE (WE MUST HAVE IF CORPORATION) |
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Required Authorization Signature Below |
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| AMOUNT OF CREDIT DESIRED MONTHLY $______________________ | |
| RESALE PERMIT #________________ CLICK HERE TO FILL OUT RESALE FORM | |
| PURCHASE ORDER REQUIRED? YES NO | |
| BILLING INSTRUCTIONS ____________________________________________________________ | |
| SHOULD GENIE AIR APPROVE THIS APPLICATION, I/WE AGREE TO PAY FOR GOODS PURCHASED WITHIN 30 (THIRTY) DAYS OF INVOICE DATE. GENIE AIR IS AUTHORIZED TO CONTACT ANY REFERENCES OR BANKS LISTED ABOVE. IT IS UNDERSTOOD THAT ANY INFORMATION OBTAINED WILL BE USED SOLELY FOR GRANTING CREDIT. SERVICE CHARGES AT THE HIGHEST RATE PERMITTED BY STATE LAW WILL BE APPLIED TO PAST DUE ACCOUNTS. SHOULD IT BECOME NECESSARY TO COLLECT THIS ACCOUNT THROUGH AN ATTORNEY, LEGAL PROCEEDINGS, OR OTHERWISE, THE UNDERSIGNED, INCLUDING ENDORSERS, PROMISE TO PAY ALL COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEYS FEES. | |
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BUSINESS NAME _________________________________________________________________________________________ STREET ADDRESS _________________________________________________________________________________________ P.O. BOX ______ P.O. BOX ZIP ______ EMAIL ___________________ URL________________ CITY __________ STATE ____ ZIP _______ PHONE# ________________ FAX# ___________ |
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| DATE
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TITLE _______________ |
SIGNATURE _____________________________ AUTHORIZED BUYER/ CO. OFFICER/ PARTNER |