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BUSINESS CREDIT APPLICATION(16)

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					                                                      BUSINESS CREDIT APPLICATION

 CONTACT INFORMATION
 YOUR NAME                                             TITLE
 EMAIL                                                 PHONE


 BUSINESS INFORMATION
 REGISTERED COMPANY NAME
 D/B/A (if applicable)                                  WEBSITE
 ADDRESS
 CITY                                STATE                                   ZIP CODE
 PHONE                                                  FAX
 TYPE OF BUSINESS : CORPORATION | SOLE PROPRIETORSHIP | PARTNERSHIP | LLC | OTHER
 LINE OF BUSINESS                        DATE ESTABLISHED                    # OF LOCATIONS
 DUNS #                                                 OTHER
 NAME OF FACTOR                          A/E                                 PHONE


 FINANCIAL STATEMENT
 PLEASE ATTACH A COPY OF YOUR COMPANY’S LATEST FINANCIAL STATEMENT.


 BANK INFORMATION
 BANK NAME                                              CONTACT NAME
 ADDRESS
 CITY                                STATE                                   ZIP CODE
 PHONE                               FAX                                     EMAIL
 TYPE OF ACCOUNT                                        ACCOUNT NUMBER


 SUPPLIER REFERENCES
 Please provide us at least three other suppliers with whom your business has established credit.
 1 | COMPANY NAME
 CONTACT NAME                                           TITLE
 PHONE                               FAX                                     ACCOUNT #
 ADDRESS
 CITY                                STATE                                   ZIP CODE
 COMMENTS
 Continue on to next page …                                                                    PAGE 1 OF 2




Fax to (972) 359.8886 | cs@jsuzette.com | Questions? Call 972-359-0001x244                    Rev 08.10.2009
                                                      BUSINESS CREDIT APPLICATION

 SUPPLIER REFERENCES
 Continued from previous page …
 2 | COMPANY NAME
 CONTACT NAME                                           TITLE
 PHONE                               FAX                                     ACCOUNT#
 ADDRESS
 CITY                                STATE                                   ZIP CODE
 COMMENTS


 3 | COMPANY NAME
 CONTACT NAME                                           TITLE
 PHONE                               FAX                                     ACCOUNT#
 ADDRESS
 CITY                                STATE                                   ZIP CODE
 COMMENTS


 INFORMATION RELEASE AGREEMENT
 1 | The undersigned (“Applicant”) agrees that the foregoing information is true and correct to the best
 of the Applicant’s knowledge.
 2 | The Applicant affirms that (s)he is legally authorized to sign on behalf of the Applicant’s company.
 3 | The Applicant authorizes the above listed financial institution(s) and business references to release
 any of the Applicant’s account, financial, and/or loan information to Nusport and its factor for the
 purpose of evaluating and approving credit for the sale of goods and/or services on credit.

 APPLICANT SIGNATURE(S)
 1 | SIGNATURE                                          TITLE
 PRINT NAME                                             DATE


 2 | SIGNATURE                                          TITLE
 PRINT NAME                                             DATE


 NOTES & COMMENTS




 Please attach additional sheets if necessary.                                               PAGE 2 OF 2




Fax to (972) 359.8886 | cs@jsuzette.com | Questions? Call 972-359-0001x244                  Rev 08.10.2009

				
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