To process your application promptly, please provide all information requested below. When a question is not applicable, write “N/A” for answer. After completing and signing this form, fax it back to us. We will promptly begin the credit review. Note:We must receive the form showing the original signature prior the release of the first shipment.

COMPANY INFORMATION

Company Name	DBA
Phone #:	Fax #:	E-mail:
Street Address:
City	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code
Type of Business   Corporation LLC Partnership Sole Proprietorship
Federal I.D #	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Tax Resale #:
Nature of Business:
Credit Line Amount Requested:	Company Annual Gross Sale	Year Established:
A/P Contact:	Phone #:	Email: