NXTEC Products CREDIT APPLICATION

P.O. Box 7185 Terms – Net 30 Days

Macon, GA 31209

APPLICANT INFORMATION:

Company Name: ________________________________ D.B.A.:_____________________________________

Street (mailing) Address: _________________________________________________________

City: __________________________ State: ________ Zip: ___________

Phone: ___________________ Fax: ______________________

Email Address: ____________________________________

Shipping Address: _______________________________________________________________

City: __________________________ State: ________ Zip: ___________

Name of A/P contact person: _________________________ Title: _________________

Phone: ______________

Type of Business: _______________________ Year established: ________

Federal I.D.#: ____________________

Dun and Bradstreet # (D&B): ____________________________________

BANK REFERENCE:

Name of bank: ____________________________________ Branch: ___________________

Street (mailing) Address: ________________________________________________________________________

City: __________________________ State: ________ Zip: ___________

Contact name:_____________________________________

Phone with area code: _________________________

Checking acct. no.:________________________

TRADE REFERENCES:

Name: ____________________________________________________________

Phone: ___________________ Fax: ______________________

Address: __________________________________________________________

City: _____________________ St: ______ Zip: __________

Account #: _________________

Name: ____________________________________________________________

Phone: ___________________ Fax: ______________________

Address: __________________________________________________________

City: _____________________ St: ______ Zip: __________

Account #: _________________

Name: ____________________________________________________________

Phone: ___________________ Fax: ______________________

Address: __________________________________________________________

City: _____________________ St: ______ Zip: __________

Account #: _________________

IS YOUR BUSINESS A: (circle one)

Sole-proprietorship Partnership Corporation Non-profit org. Government Other: _____________________

IS YOUR BUSINESS SALES TAX EXEMPT: (circle one)

Yes NO Exemption Number: _____________________________ State of Exemption: ______________

PAYMENT GUARANTEE (NET 30 TERMS):

The undersigned hereby guarantees the full, prompt, and punctual payment of all purchases made by the applicant listed above. This is a continuing guarantee until revoked in writing and acknowledged by NXTEC Products. The undersigned waives notice of any default of this guarantee and promises to pay all costs of collection and reasonable attorney’s fees incurred by NXTEC Products in the event that this guarantee of payment is placed in the hands of an attorney for collection.

AUTHORIZED SIGNATURE: _______________________________________ Title: _________________

Name (please print): ______________________________________________________

Date: __________________

FAX to: 478-994-8724 Email to accounts@nxtec.com

All information is Confidential, if you have any questions please contact us at 1-888-807-8692.