Application For Open Account Credit For Stocking Dealers

APPLICATION FOR OPEN ACCOUNT CREDIT FOR STOCKING DEALERS COMPANY NAME: D/B/A: BILLING ADDRESS: SHIPPING ADDRESS: PHONE NUMBER: FAX NUMBER: OWNER NAME: SALES TAX NUMBER: BUYER: STORE SIZE: SQ. FT. BOOKKEEPER: NUMBER OF EMPLOYEES: NUMBER OF YEARS IN BUSINESS UNDER CURRENT OWNER: PURCHASE SUBJECT TO SALES TAX? [ ] YES [ ] NO PURCHASE ORDERS REQUIRED? [ ] YES [ ] NO LINE OF CREDIT REQUESTED: $ TYPE OF COMPANY: [ ] SOLE PROPRIETORSHIP [ ] P RIVATE CORP. [ ] PARTNERSHIP [ ] PUBLIC CORP. [ ] OTHER 2001 251 American LegalNet, Inc. TYPE OF BUSINESS: BANK BRANCH: BANK CONTACT: BANK ADDRESS: PHONE NUMBER: FAX NUMBER: ACCOUNT NUMBER: TRADE REFERENCES (Please give complete addresses and account numbers): 1. COMPANY: ADDRESS: PHONE: FAX: ACCOUNT NUMBER: 2. COMPANY: ADDRESS: PHONE: FAX: ACCOUNT NUMBER: 3. COMPANY: ADDRESS: PHONE: FAX: ACCOUNT NUMBER: 4. COMPANY: ADDRESS: PHONE: FAX: ACCOUN T NUMBER: 2001 251 American LegalNet, Inc. To the best of my knowledge the above facts are represented as true. I am aware that falsification of any of this information may result in denial of credit by Inc. My signature below indicates my permission for Inc., to obtain credit information from the sources I have referenced, including any external credit reporting source, and any consumer credit agency. I understand that interest will be charged on all past due balances at a rate of % per month. Authorized By (Please Print) Signature Date 2001 251 American LegalNet, Inc.