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					                                                      CREDIT INFORMATION
  WE WISH TO OPEN AN ACCOUNT WITH NUCO2 AND SUBMIT THE FOLLOWING INFORMATION TO ENABLE YOU TO OBTAIN A
                                    CREDIT HISTORY FOR THAT PURPOSE

             INFORMATION WILL NOT BE USED OTHER THAN BY NUCO2 TO ESTABLISH A LINE OF CREDIT
FIRM NAME:


ADDRESS:


CITY:                                                   STATE:        ZIP:          YEARS IN BUSINESS:



TYPE OF BUSINESS: (check one)
         LCC              CORPORATION               PARTNERSHIP               PROPRIETORSHIP                 LLC


PRINCIPALS: (full name)                  POSITION:                                  SOCIAL SECURITY #:


                                         POSITION:                                  SOCIAL SECURITY #:


                                         POSITION:                                  SOCIAL SECURITY #:



FIRM FEDERAL ID # OR SOCIAL SECURITY #                                              STATE ID #
HAVE YOU EVER FILED BANKRUPTCY?               YES        NO
ACCOUNTS PAYABLE CONTACT:                                                           ACCOUNTS PAYABLE PHONE #
ACCOUNTS PAYABLE EMAIL ADDRESS:                                                     ACCOUNTS PAYABLE FAX #


               BANKING REFERENCE                                              ADDRESS                                   PHONE/FAX
                                                                                                                 PHONE:


                                                        CONTACT:                                                 FAX:


                                  REQUIRED RELEASE AUTHORIZATION SIGNATURE
               I hereby authorize the above named bank to release any information necessary in establishing a line of credit.


AUTHORIZED BY:                                                                      PRINT NAME:

TITLE:                                                                              DATE SIGNED:


IS YOUR LOCATION RENTED                      ______     Yes ______ No
             IF YES, PLEASE PROVIDE THE FOLLOWING LANDLORD INFORMATION (REQUIRED TO COMPLETE PROCESS):
             CONTACT NAME                ___________________________    PHONE __________________
             CONTACT ADDRESS             ____________________________________

				
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Description: credit
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