REQUEST FOR OPEN ACCOUNT

Our Credit Terms: Net 30 days from date of invoice. If these terms do not meet with your payment procedure, please contact us before completing this request.

Customer Bill To Name ____________________________________
Address ________________________________________________
City/State/Zip ___________________________________________
Phone # ______________________ Fax # ____________________

Customer SHIP TO Address(es), if different than above. (Attach a separate sheet if more than one): ________________________________________________

Corporation _____ Partnership _____ Sole Proprietorship _____
Years Established _____ Type of Business _____________
Bank Name _____________________________

Account # ______________
Owner/Corporate Officer____________________________________
Accounts Payable Contact___________________________________
Email____________________________________________________

Do you require a Purchase Order Number on invoices? _______

Names of qualified people who can purchase on account:

_______________________________________________________________

Are you exempt from Sales Tax (nonprofit, resale, government)? ____
If yes, Tax # ___________________________

(please fax a copy of your certificate).

PLEASE ATTACH THREE TRADE REFERENCES (Request will NOT be processed without them). Please include name, address, phone #,

Fax #, and contact person. Thank you!

________________________________ __________
Authorized Signature Date

________________________________ __________
Sales Contact Date