Credit Application

The information contained in this Application is provided for the purpose of obtaining or maintaining credit with you. The undersigned understands that you are relying on the information provided herein in deciding to grant or continue credit. The undersigned represents and warrants that the information provided is true and complete and that you may consider it as continuing to be true and correct until a written notice of change is given to you by the undersigned. You are authorized to make all inquiries you deem necessary including but not limited to pulling consumer credit reports on any owners or principals of the company in order to verify the accuracy of the statements made herein to determine my creditworthiness. The undersigned hereby agrees that any disputes arising out of this agreement or goods and merchandise ordered or delivered pursuant hereto will be governed and settled under applicable principles of Kansas law, under jurisdiction of the State of Kansas Courts and that venue in any such action shall be in the County of Wyandotte.

NOTE: It is understood by signing this application I am acknowledging and accepting that a service charge will be added to past-due invoices each month in the amount of 1.5% (annual rate 18.0%). Customer agrees to pay all costs of collection, including, but not limited to, attorney fees, court costs and suit fees.

Basic Information

Business Name(Required)

If dba provide details:

Company Website

Email Address(Required)

Office Phone Number(Required)

Cell Phone Number

Fax Number

Number of Years in Business

State

Federal ID Number

Business Type

Type of Work

Business Address(Required)

Mailing Address (if different)

Project/Job Location

Owners/Principals

Owner Name(Required)

Owner Title(Required)

Owner Phone Number(Required)

Personal Address

Form/Present Affiliated Companies

How Related

Bankruptcy Filed

Yes

Bankruptcy Date, City, State

Add Another Owner

Add Another Owner/Principal

Owner Name 2

Owner Title 2

Owner Phone Number 2

Personal Address

Former/Present Affiliated Companies 2

How Related 2

Bankruptcy Filed

Yes

Bankruptcy Date, City, State 2

Billing Information

Accounts Payable Contact

Accounts Payable Phone

Accounts Payable Email

Accounts Payable Fax

Preferred Invoice Delivery Method

Mail

Are you Tax exempt?

Yes

Please provide copy of exemption certificate

Drop files here or

Max. file size: 5 MB.

Do you require purchase order numbers on your invoice?

Yes

Do you require project numbers on your invoice?

Yes

Anticipated yearly purchases from Geiger Ready-Mix

Will you furnish financial statements if required?

Yes

Trade References

Please list at least three references. To add another, click the 'add another reference' checkbox.

Reference 1

Trade Reference Business Name

Trade Reference Email

Trade Reference Phone

Trade Reference Fax

Trade Reference Address

Add a second reference

Reference 2

Trade Reference Business Name 2

Trade Reference Email 2

Trade Reference Phone 2

Trade Reference Fax 2

Trade Reference Address 2

Add a third reference

Reference 3

Trade Reference Business Name 3

Trade Reference Email 3

Trade Reference Phone 3

Trade Reference Fax 3

Trade Reference Address 3

Add a fourth reference

Reference 4

Trade Reference Business Name 4

Trade Reference Email 4

Trade Reference Phone 4

Trade Reference Fax 4

Trade Reference Address 4

Previous Concrete Supplier

Previous Business Name

Previous Contact

Previous Phone

Previous Fax

Previous Supplier Address

Bank Reference

Bank Name

Bank Phone

Bank Fax

Type of Account

Bank Address

Personal Guaranty

I, ____________ residing at _______________________ for and in consideration of your extending credit at my request to ___________________ (Hereinafter referred to as the "Company"), of which I am __________.

Hereby personally guarantee to you the payment for all materials and services the entity might receive from Geiger Ready-mix Co. Inc. I hereby agree to bind myself to pay you on demand any sum which may become due to you by the Company whenever the Company shall fail to pay the same. It is understood that this guaranty shall be a continuing and irrevocable guaranty and indemnity of such indebtedness of the Company. I hereby waive notice of default, non-payment and notice thereof and consent to any modification or renewal of the credit agreement hereby guaranteed.

Signature Agreement(Required)

By signing this application, I acknowledge that I have read and understand the terms of sale and agree to abide by them.