Registration

Already have a prefilled application? Please send to AR@gtmidwest.com or fax to 316-943-7116.

Business Legal Name*

Duns #*

Billing Street*

Billing City *

Billing State*

Billing Zip/Postal Code *

Billing email* (Your E-Mail Address will serve as your User ID when you Login)

Billing Name*

Billing Phone*

Ownership Structure

Incorporated

Proprietorship

Partnership

LLC

LLP

Tax Information

FEIN*

State of Origin*

Date Formed*

Sales Tax Status

Tax Exempt (attach certificate)

Taxable

Variable (must attach list of non-taxable items)

If Subsidiary, please provide Name & Address of Parent Co.*

Purchase Orders Required?

Yes

Estimated Monthly Purchases*

Credit Limit Requested*

Bank Reference

Bank Name*

Contact information*

Account*

Trade Reference

Firm Name*

Email Address *

Phone*

Fax*

Trade Reference

Firm Name*

Email Address *

Phone*

Fax*

Trade Reference

Firm Name*

Email Address *

Phone*

Fax*

* Applicant certifies that all information contained herein is true and correct. Applicant grants permission to obtain credit reports or other information from its references and bank, and authorizes the references and bank to release information. Applicant agrees to pay all invoices in accordance with credit terms and agrees that all overdue accounts will be subject to late payment fees and interest charges. Applicant agrees to pay all collection costs for past due invoices. Applicant agrees that all goods purchased from GT Midwest remain the property of GT Midwest until paid in full. The laws of the State of Kansas shall govern all contracts between applicant and GT Midwest and all litigation will be tried in Sedgwick County.

Name*

Signature*

Title*

Date *

Applicant certifies that they are a duly authorized representative of the above legal entity.

Credit Terms offered by GT Midwest: All sales are subject to GT Midwest's Terms and Conditions. Payment is due 30 days from date of product shipment to customer. Invoices are produced individually for each purchase made on account. Invoices are emailed daily to the above billing email address. Payment to GT Midwest may be made via ACH. In the event of adverse credit conditions, GT Midwest may require a personal guaranty by the principals of the organization.

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* Indicates a Required Field

Ownership Structure

Tax Information

Sales Tax Status

Bank Reference

Trade Reference

Trade Reference

Trade Reference

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