Submit .pdf Credit Authorization

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Secure Online Credit Authorization Form

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The information contained in this document is for the purpose of obtaining credit and is warranted to be true and correct. Applicant's signature attests he/she is authorized to provide the required information and to execute this agreement. Applicant further authorizes the release of credit information including obtaining commercial and/or consumer credit reports solely for the purposes of evaluating credit by GSRx, Inc.


Applicant's signature attests financial responsibility to pay invoices from GSRx, Inc. in accordance with these terms. Any amounts due and owing for a period of more than thirty (30) days from the statement date shall be subject to a finance charge of 1.5% per month (18% per annum) simple interest, not to exceed the maximum permitted by law, which shall accrue from the due date of the payment. Applicant will be responsible for additional costs, including but not limited to collection fees, Attorney's fees, court costs and post judgment interest. I understand and agree to your terms and conditions and personal responsibility of buyers obligations. This agreement shall be enforced in accordance with the laws of the State of Iowa.

GSRx Lab terms:  Net 10 days from statement date.

GSRx credit card payments will incur a fee of 1.25%.

Your Signature

GSRx® Inc.

7440 East Karen Drive • Suite #500

Scottsdale, AZ 85260

(800) 833-GSRX (4779)

(480) 748-4546 (f)

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