D&B Rating _______________________________________

FIRM NAME __________________________________________________________________________________

Street Address _____________________________________________________________________________

City ________________________________________________ State _______________ Zip ____________

Phone ( _____ ) _____________________________ Fax ( _____ ) ________________________________

Name of Parent if Subsidary ________________________________________________________________

Name of Person in Charge of Payables ___________________ Phone: ( _____ )___________________

Fax Number of Person in Charge of Payables ( _____ ) _______________________________________

Kind of Business ___________________________________ Purchase order required? ______________

At Present Location Since (date) ________________________ Year Established _________________

Is business incorporated? _______________ If so, under laws of what state?__________________


TRADE REFERENCES: (Give only names of those you buy from on open account)

Name _______________________________________________________________________________________

Phone No. ( _____ ) __________________________ Fax No. ( _____ ) ___________________________

Street Address _______________________________________State ______________ Zip _____________

Name _______________________________________________________________________________________

Phone No. ( _____ ) __________________________ Fax No. ( _____ ) ___________________________

Street Address ______________________________________ State ______________ Zip _____________

Name _______________________________________________________________________________________

Phone No. ( _____ ) __________________________ Fax No. ( _____ ) ___________________________

Street Address ______________________________________ State ______________ Zip _____________

NOTE: Any incorrect information will cause a delay in the processing of your order.

I hereby agree to pay reasonable collection costs, attorney's fees and court costs if necessary to collect.

Full Name of Firm __________________________________________________________________________

Signed By (Officer of Firm) ________________________________________________________________

Please check basis on which you usually pay merchandise bills: Discount 30 Days 60 Days 90 Days.

The above information is correct and I agree to pay within regular terms for merchandise ordered by me or my agent delivered to the above business address.

Business Phone ( _____ ) _______________________ Signed ____________________________________

Additional information may be written on the other side of this sheet.
____________________________________________________________________________________________