Credit Application

APPLICATION FOR CREDIT

NAME

ADDRESS

CITY/STATE/ZIP CODE

FAX

TELEPHONE NO(s)

E-MAIL ADDRESS

DUN & BRADSTREET NO.

FEDERAL I..D. NO.

CORPORATION

PARTNERSHIP

PROPRIETORSHIP

Bank Reference:

BANK NAME

ACCOUNT NO

ADDRESS

CITY/STATE/ZIP CODE

TELEPHONE NO.

FAX NO.

YOU MAY ATTACH A SEPARATE LIST OF U. S. VENDORS.

TRADE REFERENCE 1

COMPANY

ADDRESS

CITY/STATE/ZIP

TELEPHONE NO.

FAXNO.

TRADE REFERENCE 2

COMPANY

ADDRESS

CITY/STATE/ZIP

TELEPHONE NO.

FAXNO.

TRADE REFERENCE 3

COMPANY

ADDRESS

CITY/STATE/ZIP

TELEPHONE NO.

FAXNO.

TRADE REFERENCE 4

COMPANY

ADDRESS

CITY/STATE/ZIP

TELEPHONE NO.

FAXNO.

CREDIT AMOUNT REQUESTED :

CREDIT AMOUNT REQUESTED $

FINANCIAL STATEMENTS MUST BE PROVIDED FOR CREDIT REQUEST GREATER THAN $50,000.00.

I (WE) HEREBY CERTIFY THAT ALL INFORMATION PRESENTED IN THIS APPLICATION FOR CREDIT IS TRUE AND THAT INTERNATIONAL COVER SYSTEMS, INC HAS THE RIGHT TO INVESTIGATE ALL RELEVANT INFORMATION IN THE PURSUIT OF ITS CREDIT INVESTIGATION

PRINTED NAME

TITLE

SIGNATURE

Please check this box in lieu of your handwritten signature.

DATE

THANK YOU FOR CHOOSING INTERNATIONAL COVER SYSTEMS FOR YOUR GEOSYNTHETIC NEEDS