Name of Firm
Date (mm/dd/yy)
,
Address
City
State
Zip
Hereby applies for credit in accordance with the terms and conditions of Gencom Transportation, Inc.
Our normal credit terms: 30 days net
The following must be provided, it will be held in the strictest of confidence.
Owership:
Name(s) of Principal(s)
Address
Phone
Finance:
Bank Name
Address
Bank Office or Department
Phone
References:
Business Name
Address
Phone
Fax
Motor Carrier Name
Address
Phone
Fax
We certify that all the information on this form is correct. We fully understand your credit terms and agree to
the proper payment in consideration of extended credit.
___________________________________________________________________________________
Signed
Title
Date
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