Customer Credit Profile Form

Please fax or mail this form to establish a credit account.

Contact Person Business Name
Phone Fax
E-mail Address:

Business Structure:
    Corporation-Publicly Held     Corporation-Closely Held
    Partnership-General     Partnership-Limited     Sole Proprietorship

Licensing Information:
 Federal Tax No.:  Resale No.:  D&B No.:

Bank Information:
Bank Name: Bank Branch:
Checking A/C No.: Contact Name:
Telephone: Fax:

Trade Reference:
Company Name Address Contact Telephone: Fax:

Company Principals Responsible for Business Transactions
Name Title Tel: Fax:

The above information are provided by:
Name Title Signature Date

PO BOX 747, Genoa, NV 89411, USA  Tel:(775) 267-5959, Fax:(775) 267-5958

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