COMPANY  INFORMATION:
Company  Name: 
Address:
City :				State:			Zip: 
Tel: 				Fax:
President:
Principal  Contact:		Title:			Phone:	
Ordering  Contact:		Title:			Phone:	
Payment Contact:		Title:			Phone:	

Type of Business:		(  ) Corporation		(  )  Partnership
				 (  ) Sole Proprietor	(  )  Other
Year Established:		Number  of  Employees:
Annual Sales Volume:		1993:		1994:		1995: (Projected) :
											
Type of Reseller:		(  ) Retailer		(  )  Other (please  specify)
				 (  ) Consultant		
				 (  ) Distributor		
                              
Sales Activities:		(  )  Store / walk-in	(  ) Mail Order
				 (  )  Direct		(  ) Wholesale
				 (  )  Domestic		(  ) International     
	
BUSINESS  INFORMATION :
State Resale Number:
(Per Sales and Use Tax Law,  please attach a copy of Company's signed resale certificate for our records.  Thank you.)
Bank Name:
Address :
City:				State:			Zip: 
Account Number:			Type of Account:
Contact:			Tel:
							 Fax:

	
BANK REFERENCES:
Bank Name:
Address :
City:				State:			Zip: 
Account Number:			Type of Account:
Contact:			Tel:
							 Fax:
	
TRADE REFERENCES :
Company Name:
Address:
City:				State:			Zip:
Contact:			Title:			Tel:
							 Fax:
	
Affiliation with referece:

Company Name:
Address:
City:				State:			Zip:
Contact:			Title:			Tel:
							 Fax:
	
Affiliation with reference:
	
Company Name:
Address:
City:				State:			Zip:
Contact:			Title:			Tel:
							 Fax:

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