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Credit Application

Fill out our Credit Application to open a line of credit with us.

Company Company:

Street Address:

City:

State:

Zip Or Postal Code:

Phone:

Fax:

Years In Business:

SIC/NAIC #:

Products / Services:

Oem User Other

Tax Exempt:

Yes No

(If tax exempt, please fax your tax exempt certificate to 414-422-2339 or scan & email to info[at]grimstad.com.)

Billing Contact Name:

Title:

Phone:

Fax:

Email:

References

	Company	Address	Phone	Contact Name
1)
2)
3)
4)

Release Of Authority To Verfiy

I confirm the above information is correct and I authorize the above credit references to release information deemed necessary by J.M. Grimstad for the purpose of approving an open account with their company. I aggree to the terms of NET 30 DAYS FROM INVOICE DATE* unless other terms are negotiated.

Digital Signature (name):

Date Signed:

*(A service charge of 1.5% per month, 18% annually will be charged on balances not paid within 30 days.)