Application for Credit

Date:

Company Name:*

Billing Address

Street:*

City:*

State:*

Zip:*

Phone Number:*

Fax Number:*

Accounts Payable Contact:*

Phone:*

E-Mail:*

Type of Company:*

Time in Business*

DUNS Number

Fed Tax ID / SSN*

Estimated annual volume of purchase:*

Institution Name*

Acct No:*

Street*

City*

State*

Zip*

Phone Number*

Fax Number*

E-Mail*

IF TAX EXEMPT PLEASE FORWARD EXEMPTION CERTIFICATE

I represent that the above information is true and is given to induce and extend credit to the applicant. My company and I authorize to make such credit investigation as sees fit, including contacting the above trade references and banks and obtaining credit reports. My company and I authorize all trade references, banks, and credit reporting agencies to disclose to any and all information concerning the financial and credit history of my company and myself.

I have read the terms and conditions stated below and agree to all of these terms and conditions.

Authorized Signer Name:*

Title:*

Date:

Invoices are sent on the day after each shipment. All invoices become payable in full 30 days (net 30) from the invoice date and if not paid by said date they will be considered past due.

If your account becomes delinquent and remains delinquent in excess of sixty (60) days, credit priveleges may be cancelled and/or future orders placed on COD.

No additional credit will be extended to past due accounts unless satisfactory arrangements are made with our credit department.

Upon consideration of granting credit, Buyer agrees to pay all costs of collection, including but not limited to reasonable attorney's fees which shall be considered to part of the total balance outstanding.