Close

 
 
IP&E Holdings, LLC (dba IP&E Guam)
Ste. 100 643 Chalan San Antonio
Tamuning, Guam 96913-3644
Tel: (671) 647-0000 Fax: (671) 649-4353
Applicant Information
 
Name:
Trade Name (if any):
Type of Business: Years of Operation: No. of Employees:
Business Location Address:
Business Mailing Address:
Telephone Number: Fax Number:
Email Address:
Partnership  Corporation  Sole Proprietor 
 
Principal Officers
 
Name Position
 
  RECENT FINANCIAL STATEMENTS ARE REQUIRED WHERE MONTHLY PURCHASES ARE TO EXCEED $5,000. ALSO, PLEASE SUBMIT A CURRENT BUSINESS LICENSE WITH APPLICATION.  
Bank Reference(s)
Bank Reference(s)
 
Name of Bank Type of Account Account Number
Checking 
Savings 
Checking 
Savings 
Checking 
Savings 
 
 

Authorization to Release Information

The undersigned authorized the above credit references to disclose financial information as requested by IP&E Guam, in connection with his application for credit with IP&E Guam and canadian pharmacy levitra its applicable companies. A copy or facsimile of this form shall be deemed acceptable to cialis daily dosage pharmacy you as proof of my (our) authorization.
 
Applicant:  Date: 
Company  Title 
Printed Name  Signature 
 
Are company officers prepared to sign personal guarantees if deemed necessary? Yes  No 
Under penalties of www.unitedvision.fr perjury, the undersigned declares that the online ordering levitra statements herein are true and correct to the best of my/our knowledge.
Authorized Representative(s) Print Name and Title


Signature


Date


please complete and sign all the above information prior to submission
 
For Office Use Only
 
Received by:   Date:  
Reference  
Notes/Comments  
 
 
 
Close

 
 
IP&E Holdings, LLC (dba IP&E Guam)
Ste. 100 643 Chalan San Antonio
Tamuning, Guam 96913-3644
Tel: (671) 647-0000 Fax: (671) 649-4353
Card Holder
 
  I,
[Print Name]
authorize IP&E Guam to charge my credit card  
 
Card & Transaction Information
 
For services rendered. Not to exceed the amount shown.
AMOUNT  $  ONE TIME CHARGE MONTHLY RECURRING 
CREDIT CARD TYPE ATTACH RECEIPT HERE
CREDIT CARD NO.
EXIPIRATION DATE
BILLING ADDRESS 
(City / State) (Zip Code)
APPLY PAYMENT TO ACCOUNT NO.
INVOICE NO.
COMPANY NAME
 
Authorization
 
NAME ON CARD (As it appears on card) 
SIGNATURE   DATE  
FAX TO:
IP&E GUAM
ATTN: LISA BLAS / MARIVIC GARCIA
(671) 649-4353
 
For Office Use Only
 
Received by:   Date:  
Reference  
Notes/Comments  
 
 
 
Close

 
 
IP&E Holdings, LLC (dba IP&E Guam)
Ste. 100 643 Chalan San Antonio
Tamuning, Guam 96913-3644
Tel: (671) 647-0000 Fax: (671) 649-4353
Company Information
 
 
Company Name
  Customer account number
Contact Person   Title   Tel No  
 
Fleet Information
CARD TYPE
C=Corporate
F=Fleet
CC=Container Card
LICENSE PLATE NO. VEHICLE DESCRIPTION MONTHLY LIMIT ($) PRODUCTS ALLOWED
(Mark where applicable)
MAKE MODEL COLOR RUL PUL ADO
 
For Office Use Only
 
Received by:   Date:  
Reference  
Notes/Comments  
 
 
 

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