Open an Account
If you or your company would like to open an account with Georgia Blue please complete the
following online credit application, Click on the Print button, sign and mail or fax to 770.452.0559

Contact Name :    Name of Company: 
Email Address:    In Business Since:
Billing Address:
Address: 
 
City:
State:
Zip:
Physical Address:
Address: 
 
City:
State:
Zip:
Phone Number:   
Line of Business: 
Fax Number: 
If Incorporated:
Name & Title of Officers:    
If Branch of Division: 
Home Office Address: Home Office Phone #:
If Sole Proprietorship: 
Name: SSN#:
Home Address:  Home Phone #:
Bank Name:
Account #(s):

Bank Address:
Phone #:
Bank Contact/Officer: 
Fax #:

Estimated Monthly Purchases: 
Credit Limit Requested: 

Tax Exempt?
Tax County
If yes, a copy of your tax exempt certification
(not the Permit) must accompany your application.

Are Purchase Orders Required?

Would you like to receive a monthly statement?

Credit References

1.) 
Name: 
Account # : 

Address:
Phone #:  Fax #: 

2.) 
Name: 
Account # : 

Address:
Phone #:  Fax #: 

3.) 
Name: 
Account # : 

Address:
Phone #:  Fax #: 

The above information is for the purpose of ontaining credit with Georgia Blue QRS and is warranted to be true. Terms are NET 30 DAYS. 1.5% per month is added to all post due invoices (10% A.P.R.) due to handling, accounting, etc. There will be a restocking charge of 15% for all stock items. Restocking of special order items will be subject to a 30% charge.

Signature of an officer of the company:

Print Name / Title__________________________________ Authorized Signature / Date________________________________

If you or your company would like to open an account with Georgia Blue please complete the following online credit application, Click on the Print button, sign and mail or fax to 770.452.0559