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COMPANY NAME ____________________________________ YEARS IN BUSINESS ________

STREET ADDRESS __________________________________ CITY/STATE/ZIP _______________

MAILING ADDRESS __________________________________ CITY/STATE/ZIP _______________

TELEPHONE # _______________ FAX# _______________ E-MAIL ____________________

TYPE OF BUSINESS __________________________________________________________

COMPANY OFFICERS: PRESIDENT _____________________________________

VICE PRESIDENT _____________________________________

SEC/TREASURER _____________________________________

BANK REFERENCES

NAME OF BANK ______________________________________ ACCT# ________________

ADDRESS ______________________________________ TELEPHONE# _______________

CREDIT REFERENCES EXPECTED LINE OF CREDIT: $_________________

1) _________________________________ FAX# _______________ PHONE# _______________

2) _________________________________ FAX# _______________ PHONE# _______________

3) _________________________________ FAX# _______________ PHONE# _______________

4) _________________________________ FAX# _______________ PHONE# _______________

SALES TAX INFORMATION EXEMPT FROM SALES TAX: YES ____ NO ____

IF YES, GIVE EXEMPTION NUMBER(S) STATE TAX# ______________________

PARISH TAX#______________________

PLEASE INCLUDE COPIES OF CERTIFICATE(S) OF EXEMPTION

FOR GATOR SUPPLY USE ONLY - DO NOT FILL IN BELOW

HOW LONG TERMS HIGH CREDIT MANNER OF PAYMENT BALANCE PAST DUE

1) _______ ______ ___________ ___________________ __________ _________

2) _______ ______ ___________ ___________________ __________ _________

3) _______ ______ ___________ ___________________ __________ _________

4) _______ ______ ___________ ___________________ __________ _________

GATOR SUPPLY OFFICER: _________________________ DATE: ___________ SLM# _______

CREDIT: ____ APPROVED ____ DENIED CREDIT LIMIT $_____________ BILL CODE ______

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