Address:

Contact Person:

Phone ( ):

Authorized Officer/Person:

Phone ( ):

Please Check One:
Individual
Partntership
Corporation
      If Incorporated, which state:

Federal Tax or S/S Number::
- Please Attach Signed Resale/Exempt Certificate

Name of Bank:	Contact Person:

Address and Phone:

________________________________________________________________________

Type of Business:	Date Started:

Please List Three Active References: Include Complete Address and Phone Number:

Credit Card Type (check one):
Master Card
Visa
American Express

Card #:	Expiration Date:

Name of Issuing Bank:

Authorzied Signature of charge credit card account on uncollected balance after 30 days
(please sign after printing):
______________________________________________________________________

Applicant's signature attests financial responsibility, ability and willingness to pay invoices in
accordance to terms. (Terms are Net 30 Days.) The above information as well as that after these
lines are for the purpose of obtaining credit and is warranted to be true.

I/We hereby authorize the firm whom this application is made to investigate the reference listed
pertaining to my/our credit and financial responsibility.

Collection costs such as attorney fees, storage, advertising, accounting and all costs incurred
through outside collection services are to be paid by debtor.
(Please fill out after printing)
Firm Name:
______________________________________________________________________
By:
______________________________________________________________________
Title:
______________________________________________________________________
Date:
______________________________________________________________________

INDIVIDUAL/PARTNERSHIP ORGANIZATIONS MUST COMPLETE THE FOLLOWING

PERSONAL GUARANTEE

I,__________________________________, residing at ___________________________
__________________________ for and in consideration of your extending credit at my
request to (name of organization______________________________________________ _______________________________________________________________________
(hereinafter referred to as the "company"), hereby personally guarantee to you the payment
of any obligation of the company and I hereby agree to bind myself to pay you on demand
any sum which may become due to you by the Company whenever the Company shall fail to
pay the same. It is understood that this guarantee shall be a continuing and irrevocable
guarantee and indemnity for such indebtedness of the Company. I do hereby waive notice
of default, non-payment and notice thereof and consent to any modification or renewal of the
credit agreement hereby guarantee.

Signature:______________________________________________________
Date: _________________________________________________________
Witness: _______________________________________________________
Date: _________________________________________________________
Address: _______________________________________________________