New Customer Credit Application

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Brock Services LLC

777 N. Eldridge Parkway,

Suite 900, Houston, TX 77079 Finance: 832-862-4243

New Customer Credit Application

The undersigned company is applying for credit with Brock and agrees to abide by the general terms and conditions as stated below.

Date of Application:

Company Name/DBA:

Business Address:

Contact Person:

Phone

Have you ever had credit with us before?

Yes

If yes, under what name?

Amount of Credit Requested:

Select Type

I have read and agree to the terms and conditions stated:

Authorized Signature:

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Date:

Printed Name:

Title:

All sales, services, and rentals are subject solely to the Brock Services LLC Terms and Conditions which can be found at www.brockgroup.com/brock -services-rental-terms and are incorporated herein as if fully set forth and shall not be altered or amended by any terms and conditions provided by Customer, including any terms and conditions linked to or provided in conjunction with Customer’s PO, unless Brock and Customer have entered into a separate, written, master services agreement, supply agreement, equipment rental agreement, or other contract which governs the work quoted herein.

CUSTOMER BILLING INFORMATION

City:

State:

ZIP Code:

Billing Address:

AP Contact Name :

Phone Number:

Email address for invoices:

Email Address for Invoices:

SALES TAX: Will you be submitting either a resale certificate or direct pay permit?

Yes

Applicable Tax Certificates

If you will be using a Louisiana resale certificate, please provide your NAICS codes.