Please provide the following contact information:

Business Name:
Fed Tax ID:
Parent Company:
P.O. Box:
Street Address:
City:
State/Province:
Zip/Postal Code:
Work Phone:
FAX:
E-mail:

Please provide business type:

Corporation
Proprietorship
Partnership
Not for Profit
Government

Please provide business information:

Date Business  Started or Incorporated:
State of Incorporation:

Is merchandise you are purchasing to be resold?

Yes No

Nevada Resale Number:

Type of products or services sold:

Please provide Corporate Officer information:

President:
Social Security Number:
Secretary:
Social Security Number:
Treasurer:
Social Security Number:

Please provide banking information:

Bank Name:
Bank Officer:
Address:
Account Number:

Please provide three trade references:

Name:
Address:
Telephone Number:
Name:
Address:
Telephone Number:
Name:
Address:
Telephone Number:

What is your estimated monthly purchase from Kent's?:

            

Is P.O. required?

Yes No

P.O. Number:

Persons authorized to sign on this account:

Name:
Name:
Name:

APPLICANT AGREES AS FOLLOWS:
1. That applicant's bank may furnish all financial information requested by Kent's.
2. That terms of sale are: net 10th of the month following billing.
3. That any overdue balance on account shall bear a finance charge at a rate to be set by Kent's that can be up to
    the  maximum allowed by law. (current rate is 2% per annum.)
4. That any portion of the account is referred to an attorney or other collection agency, applicant will pay a
     reasonable  attorney's fees for such collection including trail and appeal.
5. That as security for payment to Kent's Supply Center, Inc., applicant may be asked to sign a promissory note
     with financial statement and/or a lien form.
7. That applicant will pay a service charge of $15.00 for any returned check.

Please provide personal guaranty:

Owner or Officer:
Title
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Work Phone:
Social Security No.: