Firm Name ________________________________________

Billing Address ____________________________________

City _____________________________ ST _______ Zip Code _______________

Telephone number _____________________ Fax number __________________

Email address _______________________ Website address ________________________________

Shipping Address __________________________________

City _____________________________ ST _______ Zip Code _______________

Telephone number ______________________ Fax number __________________

Parent Company (if subsidiary) __________________________________________

Type of Business(check one) __ Individually Owned  __ Partnership  __ Corporation

Proprietors, Partners, or Principals ______________________________________________________

Whom should we contact in your store on credit matters? _____________________________________

Whom should we contact in your store with new product information? ____________________________

Year business established ___________________ At present address since ___________________

Bank _________________________________ Branch _____________________________________

Street Address _______________________________________

City ____________________________________ ST ___________ Zip Code _______________

Person to contact ______________________________________________

Amount of credit requested ____________________________

NOTE: IF YOU ARE NOT A D&B RATED COMPANY, KINDLY ENCLOSE YOUR MOST RECENT FINANCIAL STATEMENTS.

List below COMPLETE names and addresses of firms with whom you have credit. * Required for timely processing.

FIRM NAME                                        TOWN, ST                                       TEL NO.*     FAX NO.*

______________________________  ____________________________  __________  __________

______________________________  ____________________________  __________  __________

______________________________  ____________________________  __________  __________

______________________________  ____________________________  __________  __________

______________________________  ____________________________  __________  __________

AGREEMENT: The applicant hereby agrees all information provided is true and correct and further agrees to pay all bills for purchases within the terms of the sale as indicated. All payments are to be made to CHUCK ROAST EQUIPMENT at the mailing address of P.O.Box 2080, Conway, NH 03818. Should action be instituted to enforce payment of any outstanding accounts, I (We) agree to pay all cost of a suit and a reasonable attorney's fee. The obligations of the undersigned are to be performed in the County of Carroll, State of New Hampshire.

SIGNED _____________________________________________ DATE ____________

TITLE     ______________________________________________