Before you can order you must fill out our

CREDIT APPLICATION

Credit Amount Requested Date

Company NameTelephoneFax
Complete Business Address
CityStateZip
Date Business BeganState of Incorporation

Name of Partners or Corporate Officers:

(1)NameTitle

Home Address

SS# Home TelephoneYears There

(2)NameTitle

Home Address

SS# Home TelephoneYears There

Bank References:
(1)Checking:
Account NameAccount Number

Complete Bank Address

(2)Savings:
Account NameAccount Number

Complete Bank Address

Location is OwnedLeased
If Leased, LandlordsName/Phone#

Sales Tax Exempt
Yes No
If Yes, Tax ID NumberPlease Fax The Current Tax Exemption Certificate to

By submitting this application you agree that it will remain property of the lender regardless if credit has been extended. The lender is authorized to make any inquiries deemed necessary to verify theaccuracy of the information herein, including but not limited to procuring consumer reports from consumer reporting agencies: obtaining credit information from other financial institutions and extenders of credit, present past employers, and references. By submitting this application you also represent your unlimited personal guarantee in all indebtness to HELIX. If granted credit, your company will will pay 1.5% per month which is 18% yearly for past due balances. There are no lawsuits or judgments against your company at this time. If your company defaults on payment of any outstanding valid invoices, you agree to pay attourney and/or collection expenses 25% of the outstanding balance plus court costs.

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