NAME OF FIRM:

STREET ADDRESS:

MAILING ADDRESS:

OFFICERS/OWNERS:

KIND OF BUSINESS:

YEARS ESTABLISHED:

IS BUSINESS INCORPORATED? YesNo

BANK AFFILIATION

BANK OFFICER

BANK PHONE

NAMES OF AUTHORIZED BUYERS ON THIS ACCOUNT:

BUSINESS REFERENCES:

SALES TAX EXEMPTION #:

ACCTS PAYABLE CONTACT

PHONE NO

DATED