Online Credit Application

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 *

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 *

Attachments - Check the appropriate box if this document needs to be attached to the Invoice. *

Signed POD Confirmation Sheet Other None

Attachments - Other: *

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 *

ATTN: *

Other Billing Requests or Instructions: *

E-Signature *

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