Firm's Name:
Address:
City:State:Zip:
Phone #:Fax #:

Ownership: Corporation  Partnership  Proprietorship

President:
Controller:
Type of Business:Number of Outlets:
Trade Area:Estimated Annual Purchase from us: $
Date Established:Federal Tax ID:
D & B Listed:  Yes  No Rating:

BANK REFERENCE

Bank: Account # (s):
Address:
Person to Contact:
Phone #:Fax #:

MAJOR TRADE REFERENCES

1)Name:    Account #:
Address:
Person to Contact:
Phone #:Fax #:

2)Name:    Account #:
Address:
Person to Contact:
Phone #:Fax #:

3)Name:    Account #:
Address:
Person to Contact:
Phone #:Fax #:

NOTE: Applicants signature attests financial responsibility, ability and willingness to pay invoices within our terms, net 30 days from invoice date. Accounts not paid within our terms agree to pay 1-1/2% per month late payment charge, effective rate of 18% per annum upon demand of seller. In the event of default, the applicant agrees to pay reasonable collection costs and attorneys' fees.

I HAVE READ, UNDERSTAND AND ACCEPT THE ABOVE TERMS AND CONDITIONS OF SALE.
Signed By:

Title:Date: