FIRM NAME (Last/First)
PHONE
EMAIL ADDRESS

ADDRESS (City-State-Zip)

SHIPPING ADDRESS (City-State-Zip)

Legal Entity

Corporation Partnership Ind. Prop

How Login in this business

PROPRIETORS, PARTNERS OR OFFICERS (ALL MUST BE INCLUDED)

1. Name

Home Address

City State Zip

Telephone Social Security # Driver License #

2. Name

Home Address

City State Zip

Telephone Social Security # Driver License #

3. Name

Home Address

City State Zip

Telephone Social Security # Driver License #

CREDIT REFERENCES

1. Name

Address (City-States-Zip) Phone #

2. Name

Address (City-States-Zip) Phone #

3. Name

Address (City-States-Zip) Phone #

4. Name

Address (City-States-Zip) Phone #

Mortgage on machinery or equipment $ Held by

REAL ESTATE OWNED

Address City/State/Zip

MOTOR VEHICLES OWNED

Year Make LIC#

Year Make LIC#

PRESENT LANDLORD

Name

Address City/State/Zip

WHERE DO YOU BANK

Bank Branch

Phone # Banker

Account # Type of Account

Account # Type of Account

OUTSTANDING LOANS

Loan # Type of Loan

Source Telephone

Loan # Type of Loan

Source Telephone

DO YOU PLEDGE OR BORROW ON YOUR ACCOUNTS RECEIVABLE?

FROM WHOM?

HAVE YOU BEEN IN BUSINESS UNDER ANOTHER NAME? IF YES, PLEASE FURISH:

Other Business Name

Complete Address Reference

CURRENT STATUS

WILL COD SHIPMENT BE ACCEPTABLE UNTIL CREDIT IS APPROVED? YES NO

The information and statements in this application are true and complete, and are made for the purpose of inducing you to establish an open account line of credit. You are, hereby, authorized to obtain any information you consider necessary from any source concerning the statements in this application. In consideration of, and in order to induce you to establish an open account line of credit based on the foregoing application, the undersigned individually promises to pay and guarantees payment for all purchases in accordance to your terms of sale. If at any time, for any reason, the purchaser is unable to pay for such said purchases when due, the undersigned agrees to pay and authorizes you to bill my/our account interest computed at the legal rate of 1 ½ % per month on any past due amount owing on my/our account. In the event it becomes necessary for your company to incur collection costs, or to institute suit to collect any amount due under this agreement, or any portion thereof, the undersigned promises to pay such additional collection costs, charges and expenses including reasonable attorneys fees if the account is placed in the hands of an attorney or collection agency for collection.

APLLICANT'S NAME DATE