AGREEMENT TO BE COMPLETED BY APPLICANT Date Legal Business Name Trade Name (s) Company Website Delivery Address Mailing Address (if different) Telephone No Fax NoSpecial Delivery Instructions • April 11th, 2012
Contract Type FiledApril 11th, 2012TYPE OF BUSINESS CORPORATIONIndicate Officers Kind of Business SIC # D&B No # of Years This Business Under Current Ownership PARTNERSHIPIndicate Partners Other Locations Currently Owned Tax Exempt/Resale # (Attach copy of certificate) PROPRIETORSHIP Indicate Owner Line of Credit Requested Anticipated Monthly Purchase