Who is your GPC sales rep and/or CSR? *

Multiple selections allowed

Allison Balke

Kim Bell

April Brenner

Shaun Cowles

Jim Daniel

Terry Durham

Amy Flanagan

Lauren Furlo

Rod Hoeks

Danielle Homrich

Mark Idema

Alan Kebless

Tony Trevino

Mike Wilkinson

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

AP Contact Name *

First Name

Last Name

AP Phone Number (Office/Direct) *

Country

(###)

###

####

AP Phone Number (Alternate)

Country

(###)

###

####

Sales Tax Status *

Subject to Tax

Exempt from Tax

Resale

Tax Exempt Organization

Industrial Processing

Completed By: *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized Employee *

I agree to reimburse the seller for any deficiencies imposed by the state for violation of such rules and and regulations. This agreement shall remain in effect for the period of which the state shall hold the seller liable, and shall apply to all purchases until buyer shall advise in writing to the contrary. Note: Typed name (electronic submission) will be used in lieu of signature.

First Name

Last Name

Type of Classification *

C Corporation

S Corporation

Individual/sole proprietor

Limited liability company (LLC)

Partnership

Other

Contact Name *

First Name

Last Name

Contact Phone Number *

Country

(###)

###

####

Business Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address

Use this field if Physical Address is different than Business Address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Remit To Address

Use this field if Remit to Address is different than Business Address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Credit Amount Requested *

Note: Using the contact information provided on this form, Our Accounts Payables team will reach out to you for Trade and Bank References, if required.

$500 or less

$1,000

$2,500

$5,000

$10,000

Over $10,000

Purchase Orders Required? *

Yes

No

Will you honor invoices for work produced on orders from any of your employees? *

Yes

No

Authorized Company Officer *

Note: Typed name (electronic submission) will be used in lieu of signature.

First Name

Last Name