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

Multiple selections allowed

Allison Balke

April Brenner

Shaun Cowles

Terry Durham

Lauren Furlo

Rod Hoeks

Danielle Homrich

Mark Idema

Tony Trevino

Mike Wilkinson

Makayla Velderman

Winifred Vanharen

Joe Davis

Alan Kebless

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

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