CUSTOMER

• Complete Legal Name*
• Telephone*
• Email*
• Address :
• City :
• State :
• Zip Code :

DESCRIPTION OF BUSINESS

• Annual Sales :
• In Business Since :
• No. of Employees :
• Amount of Credit Requested :

BUSINESS STRUCTURE

• Corporation-publicily held :
• Corporation-closely held :
• Partnership-General :
• Partnership-Limited :
• Sole Partnership :
• If a divison or subsidiary, name of patent corporation :

LICENSING INFORMATION

• Federal Tax No. :
• Resale No. :

BANK REFERENCES

• Name :
• Branch Location :
• Telephone No. :
• Checking Account No. :
• Contact :

TRADE REFERENCES(open account only)

Reference ( 1 )

• Firm Name :
• City :
• Fax No. :
• Telephone No. :
• Contact Name :

Reference ( 2 )

• Firm Name :
• City :
• Fax No. :
• Telephone No. :
• Contact Name :

Reference ( 3 )

• Firm Name :
• City :
• Fax No. :
• Telephone No. :
• Contact Name :

Reference ( 4 )

• Firm Name :
• City :
• Fax No. :
• Telephone No. :
• Contact Name :

COMPANY PRINCIPALS RESPONSIBLE FOR BUSINESS TRANSACTIONS

• Name :
• Position :
• %Ownership in Company :
• SS# if partnership or pro. ship :
• Home Address :
• City :
• State :
• Zip Code :

IS P.O. # required?

• Yes :
• No :

PERSONS AUTHORIZED TO PURCHASE

• Name :
• Title :
• Telephone No. :

• Name(Please Print) :
• Title :
• Social Security #
• Home Address, City, State, Zip

• Signature
• Date :
• Home Phone :