Name 
	Title 
	Company 
	Address 
		 
	City 
	State/Province 
	Zip/Postal code 
	Country 
	Phone 
	Fax 
	E-mail 

1) Type of Organization:
	CorporationPartnershipProprietorship	
2) Country/State of Incorporation
	
3) Federal I.D.# 
4) Date Business Started 
5) Type of Business:
	Distributor/AgentOEM (Original Equipment Manufacturer)End UserContractorGovernment
6) Annual Sales Volume $
7) Accounts Payable Contact 
8) Second A/P Contact 
9) List all Officers or Partners
	
10) Bank Name 
	Address 
	City 
  	State/Province 
 	Zip/Postal code 
	Country 
	Phone# 
	Account# 
11.) List Four Trade References -
	1) Name 
	Address 
	City 
  	State/Province 
 	Zip/Postal code 
	Phone # 
	Fax #  (very important)
	Billing contact 
	2) Name 
	Address 
	City 
  	State/Province 
 	Zip/Postal code 
	Phone # 
	Fax #  (very important)
	Billing contact 
	3) Name 
	Address 
	City 
  	State/Province 
 	Zip/Postal code 
	Phone # 
	Fax #  (very important)
	Billing contact 
	4) Name 
	Address 
	City 
  	State/Province 
 	Zip/Postal code 
	Phone # 
	Fax #  (very important)
	Billing contact 
12) Amount of credit requested: $

By sending this form I certify that all the information on this form is correct and we fully understand your credit terms are net 30 days. Past due accounts will be charged 1.5% per month (18% annual rate) on the past due balance. Shipments will not be made to accounts over 45 days. Orders will be placed on hold at 60 days and credit will be terminated at 75 days. We further agree to be liable for all legal fees on invoices referred to a collection agency or attorney.