Business Name__________________________________Date______________

Address______________________City__________State_________Zip_____

Owner/Manager_______________________________Tel.No.______________

How long in business________________________D & B Rated__________

Trade References：

Name_______________________________Address_______________________

Name_______________________________Address_______________________

Name_______________________________Address_______________________

Name_______________________________Address_______________________

Bank References：

Name_______________________________Address_______________________

Name_______________________________Address_______________________

Credit line requested $_________________________________

Pending lawsuits against Company：

___________________________________________________

___________________________________________________

___________________________________________________

The undersigned authorizes inquiry as to credit information. We further acknowledge that credit privileges， if granted， may be withdrawn at any time.

_______________________________