Fill and Sign the Iwe Authorize Any Government Agency Be it Federal State or County to Furnish Information to

Individual Credit Application Date: Customer Name: Mailing Address: Street Address: City & State: Zip Code Business Phone: Home Phone Persons to use this account Are: NAME SOC. SEC. # RELATIONSHIP ADDRESS PHONE Name and Address of Nearest Relative Not Living with You Bank Account Numbers Loan Officer Other Accounts: Loans From Loan Officer Employment Years Age Spouse’s Name Credit References Address In consideration of the extension of credit by ______________________________, the undersigned purchaser hereby agrees that the terms and conditions of all sales are as follows: 1. Terms of sale are: Net Due 10th of each month following purchases. Invoices not paid within such time are past due and subject to service charge of __________ percent per month (effective rate ___________ percent per annum). 2. Should this account upon default, be collected by or through an attorney at law, the unde rsigned agrees to pay reasonable attorney’s fees in addition to the principal indebtedness and interest thereon. 3. Purchaser agrees to examine all invoices and statements promptly upon receipt and to notify seller immediately of any failure of delivery, shortage, discrepancy, or error, and further agrees that such invoice or statement shal l be presumed correct unless he or it shall notify seller in writing of such failure of delivery, shortage, discrepancy, or error within thirty (30) days of his or its receipt of such invoice or statement, which shall be presumed to have been rec eived on or before the fifteenth (15th ) day of the month succeeding purchases. 4. Seller disclaims all warranties, express or implied, to the extent permitted. 5. Purchaser agrees to immediately examine shipment and agrees to notify seller prom ptly of any errors in shipment and of any defective material supplied. 6. Use of material shall constitute a waiver of any error in shipment or defect in m aterial which might have been determined by a prompt and diligent inspection thereof. 7. I/We authorize any government agency, be it federal, state, or county to furnish inform ation to __________________________________. NOTICE: DO NOT SIGN AGREEMENT UNTIL YOU HAVE READ AND UNDERSTAND THE TERMS AND CONDITIONS THEREOF. Signature Signature