The Following Statement Is for the Purpose of Obtaining Credit. the Undersigned Expressly

C R E D I T A P P L I C A T I O N (Pg 1 of 2)

The following statement is for the purpose of obtaining credit. The undersigned expressly guarantees that the person(s) or business applying for credit is solvent and has the ability to pay the charges intended by applicant.

Legal/Trade Name ________________________________________ Phone (____)_____________

Fax (_____)_____________

Street __________________________City ___________ County________ State _____Zip_______

Address for invoices if different than above: ______________________________________________

I/We are a Corporation ________ Partnership _________ or Sole Proprietor_________

Date of Inception ___________ State __________ Fed Tax ID # __________________________

Number of Employees __________ Annual Revenues __________________

Are you sales tax exempt? (Circle One) YES NO

If you are sales tax exempt, a valid tax exemption certificate is required PRIOR to processing orders.

Name/Phone of accounts payable person: _____________________________________________

FAX No. _______________________ E-Mail __________________________________________

Address for invoices if different from above:____________________________________________

Will a purchase order be required for each job? ______ Yes ______ No

Have you or the applicant ever declared bankruptcy or had a judgment or garnishment filed against you?

Yes ____ No _____ When____________________________________

Is Business Property Owned? _____________ Leased? ______________

Lessors Name/Address: ____________________________________________________________

It is acknowledged that ACH Foam Technologies, Inc. will make inquiries of national credit agencies regarding the applicant and may periodically run credit reports. If credit is granted, be it understood that all purchases are due and payable within 30 days from date of invoice and Applicant agrees to pay any reasonable attorney fees, late fees, court costs and collection fees associated with collection. Bank & trade references as well as other information attached are hereby incorporated into this application. In the case of dispute, ACH Foam Technologies, Inc. will determine the county for negotiation or other legal action related to the account.

ACH Foam Technologies reserves the right to put an account on hold if there are any balances outstanding, returned checks or if any discrepancies occur. If a dispute arises under this agreement, the customer consents to jurisdiction and venue in the county designated by ACH Foam Technologies, Inc.

SIGNATURE OF OWNER/OFFICER WITH AUTHORITY FOR CREDIT DECISIONS:

________________________________________ Date __________

Printed Name/Title_______________________________________

Salesman ____________

Est Cust Req _________

ACH FOAM TECHNOLOGIES, INC.

Credit Application (Pg 2 of 2)

BANK & TRADE REFERENCES

Bank Name ___________________________________________________________

Officer _________________________________ Phone (______) ________________

1. Trade Reference _______________________________Contact ________________________

Address ________________________________ City _____________ State ______ Zip _______

Phone (______) ________________Fax (____) ________________Email___________________

2. Trade Reference _______________________________Contact ________________________

Address _______________________________ City ______________ State ______ Zip _______

Phone (______) ________________Fax (____) ________________Email____________________

3. Trade Reference _______________________________Contact ________________________

Address _______________________________ City ______________ State ______ Zip _______

Phone (______) ________________Fax (____) ________________Email____________________

4. Trade Reference _______________________________Contact ________________________

Address _______________________________ City ______________ State ______ Zip _______

Phone (______) ________________Fax (____) ________________Email____________________

PLEASE PROVIDE THE FOLLOWING INFORMATION ON PRINCIPALS OF THE BUSINESS:

1. Name _______________________________Position ___________________________________

Address__________________________________City ______________ State _____ Zip ________ Soc Sec Num ____________________ Home Phone (_____) _______________

Drivers License: State _________ Number ___________________________

2. Name _________________________________Position_________________________

Address__________________________________City ______________ State _____ Zip ________ Soc Sec Num _____________________ Home Phone (_____) __________________

Drivers License: State _________ Number ___________________________

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