9040 LESLIE STREET, SUITE 212 RICHMOND HILL, ON, L4B 3M4

TEL (905) 707-6611 FAX (905) 707-6711

APPLICATION FOR CORPORATE CHARGE ACCOUNT

Date ___________________________

Company Name ___________________________________________

Telephone: ___________________________________ Fax # ___________________________________

Address: _______________________________________________________________________________

_______________________________________ Postal Code ____________________________

Principles: _____________________________________ Position: ______________________________

_____________________________________ Position: ______________________________

Nature of Business: ______________________________________________________________________

Length of Time in Business: _______________________________________________________________

Bank: ____________________________________________________

Branch: ______________________________________ Account # ______________________________

Monthly Credit Required: $______________________________

Terms of Payment: DUE UPON RECEIPT / 2% CHARGE ON ACCOUNTS PAST 30 DAYS

Credit References: _______________________________________________________________________

_______________________________________________________________________

I ___________________________________ AM THE ________________________________ (TITLE)

OF THE ABOVE NAMED COMPANY AND I AM AUTHORIZED TO APPLY FOR A CHARGE

ACCOUNT ON BEHALF OF THE COMPANY.

_______________________

Signature of Applicant