Application for Credit

COMPANY NAMEADDRESSPHONEFAX NUMBER

HEREBY APPLIES FOR CREDIT IN ACCORDANCE WITH THE TERMS AND CONDITIONS OF:

TO:

PumpRite, Inc.205 E. Butterfield Rd., #242, Elmhurst, IL 60126

CONTACT:: Adam Krzyzanowski
EMAIL:: Sales@pumprite.com
FAX:: 1-630-578-1480
PHONE:: 630-890-7867
CREDIT TERMS:: NET 30 DAYS

THE FOLLOWING INFORMATION MUST BE PROVIDED. IT WILL BE HELD IN THE STRICTEST CONFIDENCE

Ownership:

CORPORATIONPARTNERSHIPINDIVIDUAL

NAME(S) OF PRINCIPAL(S)COMPLETE ADDRESSPHONE NUMBER

Finance:

BANKBANK ADDRESSBANK OFFICER OR DEPARTMENTPHONE

BUSINESS REFERENCES

1

BUSINESS NAMECOMPLETE ADDRESSPHONEFAX NUMBER

2

BUSINESS NAMECOMPLETE ADDRESSPHONEFAX NUMBER

3

BUSINESS NAMECOMPLETE ADDRESSPHONEFAX NUMBER

4

BUSINESS NAMECOMPLETE ADDRESSPHONEFAX NUMBER

CHECK HERE IF CASH SALES ARE OKAY UNTIL CREDIT IS APPROVED.

WE CERTIFY THAT ALL THE INFORMATION ON THIS FORM IS CORRECT. WE FULLY UNDERSTAND YOUR CREDIT TERMS AND AGREE TO THE PROPER PAYMENT IN CONSIDERATION OF EXTENDED CREDIT.

SIGNED:DATE:TITLE:

** IF TAX EXEMPT, PLEASE FAX CERTIFICATE WITH CREDIT APPLICATION