For new accounts, please print out a copy of the Credit Application, complete and sign.
Then fax or mail to Great Basin.
3175 W. Ali Baba Lane,
Suite #803
Las Vegas, NV 89118
Tel: (702) 895-9033
(800) 634-6786
Fax: (702) 895-9231

CREDIT APPLICATION
Name of Firm:
Address:
City: State: Zip:
Phone:
Kind of Business:
Form of Organization:   Corporation: Partnership: Sole Owner:
Names of Officers/Owners of Firm:

President/Owner:_________________________________________________

Vice President/Partner:____________________________________________
Date Established: State of Incorporation:

TRADE REFERENCES

NAME ADDRESS PHONE#
1.
2.
3.

BANK REFERENCES

BANK NAME CONTACT PHONE#
 
ADDRESS ACCT NO.
 
PLEASE NOTE: The undersigned acknowledges that all purchases are due and payable within the normal terms of sale, which are 2% 10 days net 30 days. The undersigned agree to comply with the credit terns of net cash 30 days after date of invoice and agree to pay a late charge of 1.5% per month (18% per year) on unpaid balances past 30 days. To induce the granting of credit to the above named firm, the undersigned official hereby guarantees the company's payment of any and all purchases.
Firm Name:
Sign: Title: Date:
Please Print Name: