Credit Application

Terms and Conditions

The undersigning Company listed on this application hereby applies for credit in accordance with the terms and conditions of Gulf Coast Safety Council ("GCSC"), 170 James Drive East, St. Rose, Louisiana, 70087.

Information submitted will not be shared with or sold to any other entity and will be held in the strictest confidence.

Terms for Payment
GCSC is a non-profit corporation, supported entirely through modest annual membership dues and fees assessed for class attendance. All classes are offered at the lowest affordable fees.

If an invoice has not been paid sixty-(60) days following attendance, the respective company will be unable to receive further training from GCSC. Clients can help maintain the low fee structure by processing invoices for prompt payment.

Terms of Payment Acceptance
The undersigning Company certifies that all information on this application is correct, terms are understood, and in agreement to proper payment in consideration of extended credit.

Do you agree to the terms and conditions listed above? * I agree I disagree
NOTE: If "I disagree" is checked, your application will automatically be rejected.
Full Company Name (No Acronyms) *
Company Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Office Phone * - (###) - ### ####
Office Fax * - (###) - ### ####
Applicant Name * First Last
Applicant Title *
Applicant Email *
Federal Identification # *
Organization Type *
Incorporated in the last 12 months? *
Name of Principal - 1 * First Last
Address - 1 *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - 1 * - (###) - ### ####
Name of Principal - 2 (If Applicable) First Last
Address - 2
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - 2 - (###) - ### ####
Name of Principal - 3 (If Applicable) First Last
Address - 3
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - 3 - (###) - ### ####
Financial Institution
Name of Bank *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Name of Bank Officer * First Last
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
References
Company Name - 1 *
Contact Person - 1 * First Last
Mailing Address - 1 *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - 1 * - (###) - ### ####
Fax - 1 * - (###) - ### ####
Company Name - 2 *
Contact Person - 2 * First Last
Mailing Address - 2 *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - 2 * - (###) - ### ####
Fax - 2 * - (###) - ### ####
Company Name - 3 *
Contact Person - 3 * First Last
Mailing Address - 3 *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - 3 * - (###) - ### ####
Fax - 3 * - (###) - ### ####

Credit Application

Credit Application

Financial Institution

References