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Gemsource Credit Application
Please provide the following information:

I, , an authorized agent of , attest that the following information is true and accurate. I hereby authorize Gem Source International to use the information given for credit check purposes, including, corporate and individual credit verification for the applicant company and any and all principals or owners. Application dated: 12/13/2017

I HAVE READ AND AGREED TO CREDIT APPLICATION TERMS & CONDITIONS

Applicant Information:
Kindly complete the following credit application in its entirety. This form must be submitted by an authorized agent of your company.

COMPANY NAME: 
D/B/A NAME: 
STREET: 
STE/APT NO: 
CITY: 
    ST:     ZIP: 
YEARS IN BUSINESS: 
  JBT#: 
 
 
ATTENTION: 
    TITLE: 
PHONE: 
  FAX: 
EMAIL: 
 
 
Trade References:
Please provide three(3) US trade references

COMPANY NAME: 
STREET: 
CITY: 
    ST:     ZIP: 
PHONE: 
  FAX: 
ATTENTION: 
    TITLE: 
 
 
COMPANY NAME: 
STREET: 
CITY: 
    ST:     ZIP: 
PHONE: 
  FAX: 
ATTENTION: 
    TITLE: 
 
 
COMPANY NAME: 
STREET: 
CITY: 
    ST:     ZIP: 
PHONE: 
  FAX: 
ATTENTION: 
    TITLE: 
 
 
Bank References:
Please provide two(2) bank references

BANK NAME: 
STREET: 
CITY: 
    ST:     ZIP: 
PHONE: 
  FAX: 
ATTENTION: 
    TITLE: 
ACCOUNT TYPE: 
 
 
BANK NAME: 
STREET: 
CITY: 
    ST:     ZIP: 
PHONE: 
  FAX: 
ATTENTION: 
    TITLE: 
ACCOUNT TYPE: 
 
 
 



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