*Name of Business:

*Resale No.:

Business Type:     Storefront     On-Line     Catalog

Year Established:

*Owners/Officers:
       1: Title:
       2: Title:

*Address:

*City:

*State/Province:

*Zip/Postal code:

*Country:

*Telephone:

*Email Address:

Fax:

Product Mix:

Annual Sales:

Mail Order (%):

Credit Limit Desired:

Website Address:

*1. Name:

*Acct #:

*Address:

*Phone#:

*Fax#:

*2. Name:

*Acct #:

*Address:

*Phone#:

*Fax#:

3. Name:

Acct #:

Address:

Phone#:

Fax#:

4. Bank Name:

Acct #:

Address:

Phone#:

Fax#:

Line of Credit? (Check if Yes)     

Name of Applicant:

Title:

Date:

In the event of default, Applicant/Guarantor is responsible for reasonable attorney's fees and all costs and expenses incurred by creditor in collecting indebtedness.

Comments: