Contract Packs / All Documents / Extending Credit to Client Application

Date: Account Manager

Credit Limit Requested:

Name of Business

Telephone: Fax:

If billing address is not the same as above. Ownership Individual: Y/N Partnership: Y/N Corporation: Y/N. Name(s) of Corporate Officers, Owners or Partners.

Job title of signator, authorized signature or signer.

Date Incorporated: Duns #:

SIC#: # of Years in Business:

If you are requiring Tax-Exempt Status, please attach appropriate documentation.

Tax Exempt #: State:

Accounts Payable

Name: Telephone:

Will a purchase order be required: Y/N. Please list names of individuals, agents or employees authorized to order, receive or pick up products and materials. Job title of signator, authorized signature or signer.

Trade References:

Banking Information:

Type of Account: Savings: Y/N Checking: Y/N Credit: Y/N.

Institution Name: Account #:

Address: Contact:

City: Job title of signator, authorized signature or signer.

State, Postal: Telephone:

I, the undersigned, do hereby attest to the financial responsibility, ability and willingness to pay our invoices in a timely manner and in accordance with the Net terms circled below. I understand that a 1.5% per month late charge may be applied to any outstanding or overdue balance owed Company Name. Signature: Job title of signator, authorized signature or signer.

For all new customers or new orders, all balances must be prepaid in full. For orders made subject to a credit application, please allow for 3 - 5 business days for processing and review. All credit terms offered are subject to a verification of the application information and the customer's credit history and references. All customers will be subject to any taxes, tariffs or other levies imposed upon goods and services as required by State or Federal law unless proper resale or exemption documentation is presented to the Company.

Assigned Customer Account Number:

Assigned By signator, authorized signature or signer

Date:

Account Payment Terms: (Circle One) COD / Net 30 Days / Net 60 Days / Net 90 Days.

Account Representative Assigned to Customer : Phone Number:

Department or Group Number: