Credit Application

Company Name __________________________________________________________
Billing Address _____________________________ City ___________________ State _____ Zip ______________
Phone ___________________ Fax __________________ Email Address_________________@________________

Type of Business: Corp. ____ Partnership____ Sole Proprietorship ____ LLC _____ ; # of Employees________

Year Business Established________ Federal ID #  _____________ DUNS #_____________ D&B Rating________
Accounts Payable Contact ___________________  Telephone # _____________________ Ext. ______________
Anticipated Credit Limit $_______________  Tax Resale Number: _________________________       

  (Note: If purchases are for resale, please enclose a completed resale certificate)                        

                      List Principal Owners and Officers - Use separate sheet if necessary

1. Name ______________________________________ Title______________________________ 

2. Name ______________________________________ Title______________________________ 

Name of Bank ____________________________ Contact Name _____________________________________
Address_____________________________________City____________________________________________ 
State______Zip _________Phone ______________________  Bank Account # _________________________
Current Trade References - (List only vendors who will give information over the phone)

1. Name_______________________________________Address________________________________ 
    City ________________________________State ______Zip ___________ Phone #_______________
2. Name_______________________________________Address________________________________ 
    City ________________________________State ______Zip ___________ Phone #_______________
3. Name_______________________________________Address________________________________ 
    City ________________________________State ______Zip __________ Phone #________________  

Please indicate the basis on which you will pay merchandise bills: 
Credit Card (Visa or MasterCard)____ 30 Days ____ Pre-Paid______ Other: _______________________

The applicant authorizes the use of this document as permission to release information to PediFix, Inc.  Applicant agrees to pay for all goods purchased either by credit card at time of purchase or, if open
account is granted, within 30 days of receipt of goods.

Print Name & Title _______________________________________________________________________ 
Signature __________________________________________________ Date________________________