LEGAL STATUS : SOLE PROPRIETORSHIPCORPORATIONPARTNERSHIPOTHER (SPECIFY)

COMPANY LEGAL NAME:

OPERATING/TRADE NAME (IF DIFFERENT):

BILLING ADDRESS:

CITY:

STATE:

ZIP:

CONTACT:

PHONE:

EMAIL:

AP CONTACT:

PHONE:

AP EMAIL:

**By providing an AP email, you are authorizing all correspondence to be sent via email**

IS YOUR COMPANY TAX EXEMPT? IF SO, PLEASE PROVIDE US WITH YOUR TAX EXEMPTION FORM.

SHIPPING ADDRESS (IF DIFFERENT):

CITY:

STATE:

ZIP:

OWNER(S)/OFFICERS(S):

YEARS IN BUSINESS:

BANK:

HAVE ANY OF THE ABOVE OFFICERS EVER BEEN INVOLVED IN A PERSONAL OR CORPORATE RECEIVERSHIP OR BANKRUPTCY ? YesNo

ADDRESS:

CITY/ST:

ACCOUNT #

BANK CONTACT:

TRADE REFERENCES

NAME:

ADDRESS:

PHONE/FAX:

NAME:

ADDRESS:

PHONE/FAX:

NAME:

ADDRESS:

PHONE/FAX:

OFFICER'S SIGNATURE:

TITLE:

We hereby apply to Carson Supply, Inc. for a line of credit. We hereby acknowledge and accept Carson Supply, Inc. terms of sale as Net 10th of every month. I/ We warrant that the information provided is true and is given for the purpose of obtaining goods from Carson Supply, Inc. on a credit basis. I/ We hereby authorize Carson Supply, Inc. to use and verify the above information in any area deemed necessary. Interest on accounts which are more than 60 days past due will accrue at the rate of 18% per annum, based upon the amount of any past due balances.

PERSONAL GUARANTEE

The undersigned certifies the above information to be correct that is submitted for the purpose of obtaining credit, and agrees to all the terms and conditions of sale of the company to whom it is submitted. In consideration of credit being extended or other financial accommodations to the above firm by Carson Supply, Inc., the undersigned, personally, jointly, and severally unconditionally guarantee to Carson Supply, Inc., the prompt payment when due or become owing to Carson Supply, Inc. from the above named applicant for credit. The undersigned further guarantees the payment of all interest, attorney's fees, court costs and other costs of collection which may be incurred by Carson Supply, Inc. All applicants must notify Carson Supply, Inc. immediately of any change in business name, address, and/or principal by certified or registered mail. All charges for merchandise sold under this account are expressly payable in Dallas, Dallas County, Texas.

Signature:

Signature:

*Please return completed credit application to sales representive or email to "[email protected]"

For Office Use Only:

Inside Sales Rep:

Outside Sales Rep:

Price Class:

Home Branch:

Credit Limit Request: