Date___________________
Fax#_______________________________Telephone#_________________________________  Name________________________Title___________________
Shipping Address______________________________________________________________
Invoice  Address ______________________________________________________________
Ownership:                   Corporation_____           Partnership_____          Proprietorship_____
Name of Parent Company______________________________________________________
Description of Business_________________________________________________________
Will Items be Purchased for Resale______________State Resale Number__________________
How Long at Present Location_____________________Year Established__________________
Accounts Payable Contact______________________
Persons Authorized to purchase___________________________________________________

Bank Reference:
Name___________________________________Telephone#___________________________ Address______________________________________________________________________
Contact_____________________________Account Number____________________________

Supplier References:
Name_________________________________________________________________________ Contact___________________________Telephone#___________________________________ Address_______________________________________________________________________
Name_________________________________________________________________________ Contact___________________________Telephone#___________________________________ Address_______________________________________________________________________
Name_________________________________________________________________________ Contact___________________________Telephone#___________________________________ Address_______________________________________________________________________

All credit information developed from the given references will be kept in strict confidence.
Applicant's signature attests financial responsibility, ability and willingness to pay our invoices in accordance with our terms:

BY______________________________

TITLE___________________________