Please fill out the Credit Application form for us or download and fill out the PDF version and fax it to us. We will reply as quickly as possible.

Company Name:

Street Address:

Billing Address:

Organization Type:

Corporation
Sole Proprietorship
Partnership

Phone:

Fax:

E-Mail:

Nature of Business:

Years In Business:

Desired Credit Limit:

Home Address:

Please List Those Who Are Authorized To Pick Up Equipment:

Do You Require Purchase Order Numbers?

Yes
No

For damage waiver exemptions - please send a certificate of insurance with Great Plains Rent-All as the certificate holder.

Are You Tax Exempt?
(If yes, please send a copy of your certificate)

Yes
No

Please List Trade References:

Reference Name #1:

Reference Address #1:

Reference Phone #1:

Reference Name #2:

Reference Address #2:

Reference Phone #2:

Reference Name #3:

Reference Address #3:

Reference Phone #3:

Bank Information

Bank Name:

Bank Address:

Contact Person at Bank:

Bank Phone:

A finance charge of 1 1/2% of the unpaid invoice will be assessed at 30 days.

I, hereby certify to the above statements and agree to abide by the credit terms set forth by Great Plains Rent-All.

Date: