Credit App

Credit Application

Print Out Form Below, Complete and Fax for Credit Application

COMPLETE ALL APPLICABLE SPACES

Date:________________________________

Full Legal Name:_________________________________________________________________

Street Address:__________________________________________________________________

City, State:_____________________________________________________________________

Ship To Address:__________________________ Phone:____________________________

(If Different) __________________________ Fax: ____________________________

Credit Card # ___________________________________________________________________

If paying by Check _____ (please mark this box if paying by check)

FEDERAL ID No:_________________________________

Check One: Corporation______ Partnership______ Proprietorship______

State of Incorporation:______ Year Incorporated (Began Business):__________

President:_________________________ V. President:_________________________

Home Office Address:____________________________________________________

(If Division or Branch):____________________________________________________

Telephone:_____________________________

Taxable:______ Non-Taxable______ Tax Exemption Number:_____________________

(Attach Completed Exemption Certificate)

Are Purchase Orders Required:__________ Will Backorders Be Accepted:__________

Person To Contact Regarding Orders:_______________________________________

Accounts Payable:______________________________________________________

Accounts Payable Telephone:______________________________________________

BANK REFERENCE

Bank:____________________________ Officer:_____________________________

Address:_____________________________________________________________

Account Number:______________________________________________________

Telephone:_________________________________

TRADE REFERENCES

1. Company:___________________________ Address:___________________________

Account Number:________________________ Fax:______________________________

Phone:______________________________

2. Company:___________________________ Address:___________________________

Account Number:________________________ Fax:______________________________

Phone:______________________________

3. Company:___________________________ Address:___________________________

Account Number:________________________ Fax:______________________________

Phone:______________________________

The undersigned understands that the information furnished on this form is for the purpose of obtaining credit with GAMCO, INC. and that the undersigned is authorized to execute this agreement. Terms are Net 30 days from shipping date, FOB Shipping Point unless otherwise specified by GAMCO, INC.. No returned goods, unless approved in writing by GAMCO, INC. and 15% restocking charge. All past due accounts shall automatically draw interest at the highest legal rate, which currently is 1.5% per month. The undersigned will pay on demand all costs of collection, interest/late fees, and attorneys fees incurred in collecting amounts due GAMCO, INC. and will advise GAMCO, INC. via regular mail and certified letter, return receipt requested, 30 days prior to any ownership or corporation status changes and pay in full all amount due GAMCO, INC. Undersigned authorizes GAMCO, INC. to contact Bank and Trade References for any credit information on respective payments by company or facility to determine Credit Worthiness.

Company Name:___________________________________________

Authorized Signature:______________________________

Title:____________________

Web Address if available: ____________________________________

E-Mail Address if available: ___________________________________

Print Name Please:__________________________________________