Company  Name    
Company Web Site

                      Bill To:                                                 Ship To:
Address line 1    
Address line 2    
City                   
State                 
Zip                    

                                   Phone    

                 First & Last  Names             Phone #'s           Email
Purchasing    
A/P               
Please provide your Resale/Sales tax No.     

Please provide trade references for three companies that you have be doing business with for more than one year and for which you have an open account.

Company Name                            Contact Name                               Phone No.

GVC can extend terms once credit references are confirmed and after the first order has been placed using COD or Credit Card.  In either case we need to have a current credit card on file.

If you would like to establish an credit account,
please indicate the level of credit requested ->