APPLICATION FOR ACCOUNT

Date: ______PINESTATE TRADING CO.

8 Ellis Avenue, Augusta, ME 04330

Customer #: ______207-622-3741 Fax 207-626-5844

Sales Rep #: ______

Account Name: ______Store #: ______

(Store Name) (Chains should attach account list)

Street Address: ______City: State: ____ Zip: ______Phone #: ______

Home Phone #: ______Fax #: ______E-Mail Address: ______

Legal Name: ______State of Incorporation: ______

___LLC Office Address: Years in Business: ______

___Corporation

___Partnership City: ______State: ______Zip: ______

___Proprietorship

___Gov/School Federal ID#: ______Cig. Tax License #: ______

___Non Profit

Date Business Commenced or Purchased: ______Sales Tax #: ______Tax Exempt #: ______

Primary Contact Name: ______Bookkeeper: ______Phone #: ______

Business Premises: Own: _____Lease: _____ Type of Business (Circle All Applicable):Tobacco Only-Seasonal-Chain-C-Store-Kiosk

Landlord Name: ______Date and term of Lease: ______

Address: ______

City: State: Zip: Phone #: ______

ALL OWNERS/PRINCIPALS

Owner Name: Title: Social Security #:______DOB:______

Home Address: City: ______State: ______Zip: ______

Years @ Address:Have you ever filed bankruptcy? Y / N ; If yes, what state?______Do you own your own home? Y / N

Other Real Estate/Business owned:______

Owner Name: ______Title: Social Security #: ______DOB: ______

Home Address: City: ______State: ______Zip: ______

Years @ Address:Have you ever filed bankruptcy? Y / N If yes, what state?______Do you own your own home? Y / N

BANK REFERENCES

Name of Bank (Business Account): Account/Loan #: ______Contact: ______

Address: ______City:______State: ______Zip:______

Phone#: ______Fax: ______Type of Account: Savings/Checking/Loan

Name of Bank (Personal Account): ______Account/Loan #: ______

Address: ______City: State: Zip: ______

Phone#: ______Fax: ______Type of Account: Savings/Checking/Loan

TRADE REFERENCES

(Please list vendors with whom you have a credit relationship)

Primary Wholesaler:______Phone: ______Fax:______

Address: ______City: State: Zip: No. of Years: ____

Vendor:______Phone: ______Fax:______

Address: ______City: State: Zip: No. of Years: ____

Vendor:______Phone: ______Fax:______

Address: ______City: State: Zip: No. of Years: ____

TERMS & CONDITIONS

The applicant agrees to furnish financial statements upon request. If credit requested is $10,000 or greater, applicant must attach a copy of applicant’s past one/two years’ financial statements.

The undersigned customer (hereinafter, the "Customer") certifies to Pine State Trading Co. ("Pine State") that the information on this Application for Account is correct and that it is submitted for the purpose of obtaining an account. The Customer agrees to allow Bank and Trade References to release credit and account information to PineState. In the event an account is approved, the Customer applicant for account, intending to be legally bound, agrees to the following terms and conditions:

  1. The Customer agrees to pay all charges on receipt of merchandise. If the Customer is a corporation, partnership, limited liability company or other entity, the principals of the entity will sign the guaranty that is attached to this Application.
  2. In the event that payment is not received by PineState according to the established terms, PineState will charge, and the Customer agrees to pay, a finance charge at the rate of .049% per day, 18% per annum on the unpaid balance.
  3. PineState may, at its option, elect to refuse to continue to supply the Customer with any additional merchandise until the account is paid in full.
  4. In the event the account is unpaid for a period of Thirty (30) days or more from the date of delivery of the merchandise, the account may be turned over for collection. The Customer will pay all PineState’s costs of collection, including reasonable attorneys' fees. If PineState sues the Customer to collect any amounts owed and wins the suit, the Customer agrees to pay PineState actual court costs and reasonable attorney's fees as allowed by law. The Customer agrees to allow PineState to choose the court where legal proceedings will be filed and consents to jurisdiction in that court.
  5. If the Customer's account becomes past due, the Customer will allow PineState the right to repossess the merchandise from the Customer's location.
  6. In addition to any rights of PineState under paragraph 5, the Customer hereby grants to PineState a purchase money security interest in all inventories that is now or hereafter sold by PineState to the Customer, wherever such inventory is located, and in all proceeds thereof. The Customer authorizes PineState to file, in such offices and jurisdictions as PineState may elect, at Customer's expense, financing and continuation statements pursuant to the Maine Uniform Commercial Code ("UCC") and notices of PineState's security interest to other secured parties of Customer. Upon failure of the Undersigned to pay its obligations to PineState according to the established terms, PineState will have all of the rights and remedies of a secured party under the UCC in addition to all of its other rights and remedies at law, equity and under this Agreement.
  7. If any term or provision of this Agreement or the application thereof to any party or circumstance shall to any extent be invalid or unenforceable, the remainder of this Agreement, or the application of such term or provision to parties or circumstances other than those as to which it is invalid or unenforceable, shall not be affected thereby, and each term and provision of this Agreement shall be valid and enforceable to the maximum extent permitted by law.
  8. These terms and conditions may not be changed, altered, or modified unless in writing and signed by an authorized officer of PineState. This agreement shall be continuing and apply to each purchase for which Customer does not pay in full at the time of delivery.
  9. Any notation made on any form of payment for less than full payment due to Pine State shall not act as a release, waiver, or relinquishment of any claims of Pine State for unpaid or portions thereof due from Customer.
  10. Customer agrees to pay a service charge for any checks returned unpaid for any reason. Seller shall have the right to demand payment of returned checks in cash, money order or certified funds immediately and to withhold all further orders until all balances are paid.

Unconditional Guaranty of Account

Each of the undersigned, owner(s) of ______[company name], a ______[corporation][limited liability company] [partnership] ("Customer") hereby unconditionally jointly and severally guarantee(s) all obligations of Customer to Pine State Trading Co. ("Seller"), its successors and assigns. This is a guaranty of payment, not of collection. The undersigned waive(s) all defenses based on surety-ship or impairment of collateral, and waive(s) all notices.

This guaranty may be revoked only thirty days after Seller's receipt of the undersigned's written notice of revocation, and the notice of revocation shall not apply to any obligations existing as of the effective date of the revocation. The undersigned will pay all Seller's costs of collection, including reasonable attorneys' fees in enforcing this Guaranty and the obligations of Customer to Seller. This Guaranty contains the parties' entire understanding as to the undersigned's guaranty, and may only be modified by a writing signed by the undersigned and Seller.

In witness whereof, the undersigned has executed this Guaranty as a sealed instrument as of the ______day of ______, 20______

______Sign Name: (personal guaranty) Print Name:

______

Sign Name:(personal guaranty)Print Name:

______Sign Name: (corporate guaranty) Print Name: Witness: