City/State/Zip: _________________________________	State Exempt# _________ If you are Tax Exempt please forward a copy of your Tax Exempt Certificate to our office.
Phone #: _________________________
Fax #: _________________________

REFERENCES:

Name: ______________________________________ Phone # _________________

Address: ____________________________________ Contact: _________________

City/State/Zip: __________________________________ Fax # _________________

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Name: ______________________________________ Phone # _________________

Address: ____________________________________ Contact: _________________

City/State/Zip: __________________________________ Fax # _________________

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Name: ______________________________________ Phone # _________________

Address: ____________________________________ Contact: _________________

City/State/Zip: __________________________________ Fax # _________________

TERMS OF SALE: NET 30 DAYS. GENALCO RESERVES THE RIGHT TO HOLD SHIPMENTS AGAINST PAST DUE ACCOUNTS.

WE CERTIFY THAT ALL THE ABOVE INFORMATION IS CORRECT AND AGREE TO THE ABOVE TERMS OF SALE. Authorized Signature: ________________________________________ Title: _____________________________________ Date: ___________

GENALCO USE ONLY

Account # : _________________________ Approved: ________________________

Branch:__________________________________ Date: ______________________

Salesman: _______________________________