APPLICATION FOR CREDIT

Business Name:

Address:

Shipping Address:

Phone:                                                         Fax:

At Present Location Since (Date):                                                                 Year Established:

Former Business Address (If Applicable):

Type of Business:                                                                                          Year Established:

Ownership:                   Corporation                    Partnership                          Proprietorship

Resale No.                                                   Federal I.D. No.

Principal

Principal

Principal

Has the firm or any of it's principals ever been bankrupt?

If yes, please explain:

References: (Give only names of those you buy from on an open account)

Company Name:

Address:                                                                                                             Phone:

Company Name:

Address:                                                                                                             Phone:

Company Name:

Address:                                                                                                             Phone:

Bank References:

Name:                                                                                       Account No.

Address:

Name:                                                                                       Account No.

Address: