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ONLINE CREDIT APplication
customer information
*
Indicates required field
Business Name
*
Phone Number
*
Fax
*
Website
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Website
*
Date Business Started
*
Number of Livestock
*
Annual Sales
*
Annual Gross Income
Billing information
Business Name
*
Accounts Payable Contact
Name
*
Phone Number
*
Email
*
Fax
*
Billing Inclusions and Attachments
Information - Check the appropriate box if this information must appear on the Invoice.
*
Customer Reference #
Bill of Lading #
Other
None
Information - Other
*
If you selected "Other" for information that needs to appear on the invoice, please explain what else you would like to be included.
Attachments - Check the appropriate box if this document needs to be attached to the Invoice.
*
Signed POD
Confirmation Sheet
Other
None
Attachments - Other:
*
If you selected "Other" for documents that need to be attached to the Invoice, please explain what else you would like to be attached.
Email Billing / Green Initiative
Our preferred method of billing is through use of email. This allows us to send statements which list each of the invoices as well as links that will pull up scanned images of the invoices and supporting documentation.
Preferred email address to send Invoices to:
*
Other notes to assist us in emailing your invoices:
*
Mailing Instructions (if unable to accept billing via email)
Address
*
City/State/Zip
*
City, ST ZIP
ATTN:
*
Other Billing Requests or Instructions:
*
E-Signature
*
Please enter your First and Last name.
Title
*
Date (MM/DD/YYYY)
*
This information is given to obtain an open account status. The person submitting this application/executing this agreement agrees that the company he/she represents will make full payment to Giltner Ag, Inc. (henceforth Giltner Ag) upon receipt of invoice, but in no case later than thirty (30) days following date of invoice. By submitting this form, permission is granted to Giltner Ag to inquire about this company's credit worthiness from any source. The person submitting this application/executing this agreement agrees that the company he/she represents will pay all collections/attorney's fees if this account is placed for collection. The person submitting this application/executing this agreement agrees that the company he/ she represents must notify Giltner Ag in writing, and by certified mail of any change in ownership, the name, or the business structure under which credit is established.
The person submitting this application/executing this agreement has authority to bind the company he/she represents and is authorized by that company to enter into the credit application process and are subject to Giltner Ag's
Terms and Conditions
. The person submitting this application/executing this agreement acknowledges that entering his/her name into the "E-Signature" field is equally binding as a physical signature and will be liable as such. The person submitting this application/executing this agreement certifies that the above information is as complete, accurate, and true to the best of his/her knowledge.
The purpose of this form is to gather information which will help our companies work together smoothly through the billing and collection process. Please do not hesitate to contact us if there is anything we can do to better serve you.
Please review the entire form to ensure it is complete and use the "Submit" button below to submit this Online Credit Application.
Submit
Home
Consumers
Hay
Straw
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Producers
Request a Quote
About Us
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Terms & Conditions
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