PARTICULARS:

CORPORATION PARTNERSHIP PROPRIETORSHIP

LINE OF BUSINESS

NO. OF EMPLOYEES

DATE OPERATION BEGAN (UNDER PRESENT OWNERSHIP)

OFFICERS AND DIRECTORS / PARTNERS OR SHAREHOLDERS / PROPRIETOR (If Proprietor, also complete page 4)

NAME TITLE TELEPHONE 1. 2. 3.

ACCOUNTS PAYABLE CONTACT

SPECIAL INVOICING REQUIREMENTS

PO's Required? YESNO

TAX CERTIFICATE NO.

RELATED BUSINESSES

SUPPLIER REFERENCES:

NAME ADDRESS TELEPHONE FAX 1.   2. 3. 4.

FINANCIAL REFERENCES:

BANK ACCOUNT NO. BRANCH TELEPHONE (include area code)

MANAGER

TYPE OF ACCOUNT: Checking Savings Loan Line of credit

FINANCIAL STATEMENTS AVAILABLE IN CONFIDENCE: YES NO

FISCAL YEAR END

AMOUNT OF CREDIT REQUESTED (BASED ON TWO MONTHS' PURCHASES) $

HAS THE APPLICANT BUSINESS OR ANY OF ITS OFFICERS, PARTNERS, OR THE APPLICANT PROPRIETOR, BEEN PREVIOUSLY BANKRUPT:

YES DATE: NO

LEGALS:

The information provided in this application is true, accurate and complete. Authorization is given here for WINROC to receive and exchange credit information in connection with this application and any ongoing credit transactions. It is understood that WINROC has no obligation to grant credit for this, or any subsequent application. Approval of this application shall be set out in a Credit Approval Letter to the Customer. Use of the account by the Customer shall constitute its acceptance of the terms of the attached Credit Agreement and the terms of the Credit Approval Letter as amended from time to time.

NAME	TITLE
DATE:
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