APPLICATION FOR CREDIT

NOTE: You can use your own form; however, the information that is BOLD on this form MUST be included with your application.

COMPANY INFORMATION

Name:

Street:

City, State, Zip:

D & B #:

E-Mail Address:

Phone #:

FAX #:

Tax ID #:

SHIP TO ADDRESS

Street:

City, State, Zip:

Owner(s) Name(s):

Social Security # of Owner(s):

Length of Time Company Has Been in Business:

Payables Contact:

Title:

Phone:

Bank Name:

Branch:

Address:

Bank Contact:

Title:

TRADE REFERENCES (Minimum of 3 are requested.)

Vendor Name:

Address:

Phone #:

FAX #:

Vendor Name:

Address:

Phone #:

FAX #:

Vendor Name:

Address:

Phone #:

FAX #:

THIS IS NOT A PERSONAL GUARANTEE:

I hereby represent that I am authorized to submit this application on behalf of the customer named above, and that the information provided is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize Tedea-Huntleigh to investigate the references listed pertaining to my/our credit and financial responsibility. It is agreed and understood that all necessary collection and legal expenses and interest (at 18% per year) may be charged to debtor in the event of default or failure to pay for goods sold and delivered. I further represent that the customer applying for credit has the financial ability and willingness to pay all invoices with established terms.

REQUEST FOR ADDITIONAL INFORMATION

By:

Title:

Date:

Exempt Organization Sales Tax Certificate No:

Copyright(c) 1999 Tedea-Huntleigh, Inc.