PREMIUM INCENTIVE SALES, INC CREDIT APPLICATION

Please complete the following application in full sign all indicated areas.

All information supplied in or obtained through this application, will be held as confidential.

BUSINESS NAME:
BILL TO: / SHIP TO (IF DIFFERENT)
ADDRESS / ADDRESS
CITY, STATE, ZIP / CITY, STATE, ZIP
BUSINESS PHONE: / WEBSITE ADDRESS:
FAX NUMBER: / DUNS NUMBER:
TAX NUMBER

* PROPRIETORSHIP * CORPORATION * PARTNERSHIP

OWNER/PARTNERS/OR OFFICERS

NAME: / NAME:
SOCIAL SECURITY NUMBER: / SOCIAL SECURITY NUMBER
HOME ADDRESS / HOME ADDRESS
CITY, STATE, ZIP / CITY, STATE, ZIP

TRADE REFERANCES (MINIMUM 3)

# 1 NAME: / # 3 NAME:
ADDRESS / ADDRESS
CITY, STATE, ZIP / CITY, STATE, ZIP
PHONE: / PHONE:
FAX/EMAIL: / FAX/EMAIL:
ACCOUNT # / ACCOUNT #
# 2 NAME: / # 4 NAME:
ADDRESS / ADDRESS
CITY, STATE, ZIP / CITY, STATE, ZIP
PHONE: / PHONE:
FAX/EMAIL: / FAX/EMAIL:
ACCOUNT # / ACCOUNT #

BANK REFERANCE (MINIMUM 1)

NAME: / NAME:
ADDRESS: / ADDRESS:
CITY, STATE, ZIP / CITY, STATE, ZIP
PHONE: / PHONE:
FAX/EMAIL: / FAX/EMAIL:
ACCOUNT # / ACCOUNT #
CONTACT: / CONTACT:

I hereby acknowledge that the above information is true and correct and hereby authorized the release of any credit information from the above named references pertaining to my/our credit and financial responsibilities to whom this application is made.

SIGNATURE / TITLE / DATE

Bank Release Authorization Form

Dear Sir/Madam:

An opportunity to conduct business with the below referenced business has been presented to us. This organization has listed you as a banking reference.

We would appreciate you taking a moment to complete the bottom section of this form so we can ascertain this potential customer’s ability to satisfy its trade obligation with us. Any information provided will be maintained in the strictest of confidence. Please note your customer has signed this letter as a release form.

Premium Incentive Sales, Inc. /Credit Department

Kenya Phillips: Direct Line (720)509-8118 Bernadette Graff: Direct Line (720)509-8105

I GIVE MY CONSENT TO MY BANK RELEASE TO RELEASE THE INFORMATION BELOW TO PREMIUM INCENTIVES SALES, INC.

Business Name: ______Business Address: ______

Bank Name: ______Bank Account Number: ______

Bank Fax Number/Email: ______

Customer Signature: ______Date: ______

Information to be completed by bank

Checking: / Loans:
Date Opened - / Secured/Unsecured -
Average Balance - / High Credit -
Account Rating - / Balance -
NSF - / Payment Performance -
Savings: / Comments:
Date Opened -
Average Balance -

PLEASE FAX BACK TO (303) 290-0326

THANK YOU