NEW CUSTOMER CREDIT APPLICATION FORM

Today's Date

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Company Name

Bill to Address

City

State

Zip

Ship to Address

City

State

Zip

Telephone #

- -

Contact Name

Accts Payable Contact

Accts Payable Phone #

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Accts Payable Fax #

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Business References:

Name-Address-City/State/Zip - Contact - Phone

1 >

Fax# - -

2 >

Fax# - -

3 >

Fax# - -

Bank Reference Name:

Branch Address

Bank Phone #

Bank Contact

Account #

I hereby authorize release of any credit information from the references stated above by pressing the submit button below.

Note: If some or all of your purchases will be exempt from sales tax, please forward an exemption certificate to our Charlotte address listed below or fax it to (704)333-4448 Attn: Accts. Receivable — Thank You

725 providence Rd. Suite 323
Charlotte, NC
28207

Credit Card Account Holder's Name:

Credit Card Type:

Visa MasterCard Discover American Express

Credit Card Number:

Exp. Date:

January Febrary March April May June July August September October November December 2000 2001 2002 2003

SIC Code

D & B Number