+-----------------------------------+ | LAN WAN Enterprises | | | | 151 Westfield Ave, Clark NJ 07066 | | Phone: (732) 388-5285 | | Fax: (732) 382-9127 | +-----------------------------------+ Credit Application ------------------ Instructions: Fill out your responses on the dashed lines below. This form is best viewed in a monotype font (;etters of the same length). Example: Question: (answer) --------------------------------------------------------------------------- Legal Firm Name: --------------------------------------------------------------------------- Street Address: --------------------------------------------------------------------------- City / State: --------------------------------------------------------------------------- Zip Code: --------------------------------------------------------------------------- Billing Address (if different than above): --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- Phone: --------------------------------------------------------------------------- Fax: --------------------------------------------------------------------------- E-mail Address: --------------------------------------------------------------------------- Tax ID#: --------------------------------------------------------------------------- Form of Business (check one): Proprietorship ---- Partnership ---- Corporation ---- Franchise ---- Type of Business: --------------------------------------------------------------------------- Annual Sales: --------------------------------------------------------------------------- Number of Employees: --------------------------------------------------------------------------- How long have you been in business? --------------------------------------------------------------------------- Name and Title of Officers / Principals: --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- Purchasing Agent: --------------------------------------------------------------------------- A/P Supervisor: --------------------------------------------------------------------------- Credit Limit Approved: --------------------------------------------------------------------------- Bank Name: --------------------------------------------------------------------------- Bank Phone Number: --------------------------------------------------------------------------- Bank Address: --------------------------------------------------------------------------- --------------------------------------------------------------------------- Type of Account: Checking ---- Savings ---- Loan ---- Account Numbers: --------------------------------------------------------------------------- Trade References: Address: Phone: --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- --------------------------------------------------------------------------- Is the merchandise for resale? Yes ---- No ---- Resale Number: --------------------------------------------------------------------------- The above information is for the purpose of credit and is warranted. We authorize the firm to whom this application is made to investigate the reference listed pertaining to our credit and financial responsibility. By: --------------------------------------------------------------------------- Title: ---------------------------------------------------------------------------