Confidential Credit Application & Agreement

(“the company”) applies for the extension of credit by PRC Industrial Supply and submits the following information as a basis for PRC INDUSTRIAL SUPPLY consideration. PRC INDUSTRIAL SUPPLY IS HEREBY AUTHORIZED TO UNDERTAKE ANY INVERSTIGATIONS OR MAKE ANY CONTACTS NECESSARY TO VERIFY THIS INFORMATION.

Street

Mailing

City, State & Zip

Type of Business

Tax Exempt

Yes No

Sales Tax Exempt no.

Tax Exempt PDF

Established

Phone No.

Corporation

Partnership

Proprietorship

If incorporated which state incorporated

Email address for Invoices/Statements

Principal Owners of Stockholders

Name

Home Address (Street, City & State)

Title

Name

Home Address (Street, City & State)

Title

Name

Home Address (Street, City & State)

Title

Trade References

Name

Home Address

Fax #

Phone #

Name

Home Address

Fax #

Phone #

Name

Home Address

Fax #

Phone #

Name of Bank

Address

Acct. No.

Phone No.

Acct. Officer

The Company is able to meet its financial commitments and agrees expects to pay PRC INDUSTRIAL SUPPLY invoices according to the terms and contained thereon.

Name of Company

Signature