Address: ________ Fax#:

City: ________________________ State: ________ Zip Code: ____________________

OTHER LOCATIONS:

Name: _______________________________ Name: ________________________________

Address: _____________________________ Address: ______________________________

City & State: _________________________ City & State: __________________________

Corporation ( ) Partnership ( ) Proprietorship ( ) Other ( ) _______________

Year Established: _____________________ Resale No. ______________________________

Type of Business: _____________________ Accts Payable MGR: ______________________

Principal Officers (Name & Title):

___________________________________________________________________________
___________________________________________________________________________

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

1. Name: ________________________________ Phone #: _______________________

Address: _________________________________ Fax#: _______________________

City: ____________________ State: _______ Zip: _________ Contact: ___________

2. Name: ________________________________ Phone#: ________________________

Address: ________________________________ Fax#: ________________________

City: ____________________ State: _______ Zip: _________ Contact: ___________

3. Name: ________________________________ Phone#: ________________________

Address: ________________________________ Fax#: ________________________

City: ____________________ State: _______ Zip: _________ Contact: ___________

4. Bank Name: ______________________________ Acct#: ______________________

Address: _________________________________Phone#: _____________________

Loan Officer: ______________________

AUTHORIZED SIGNATURE:_____________________________________________

DATE: ___________________