Date of application:

1. Account (Legal) Name: ("Customer")
   
   Trade Name: ("Customer")
2. Shipping Address:
   Street City State Zip Code
3. Mailing Address:
   Street City State Zip Code
4. Telephone Number: Fax Number:
   
   E-Mail:
   Web Address:
5. Federal I.D. Number: S.S. Number:
   
   DUNS Number:
6. Business Type: OtherTrustSole ProprietorshipPartnershipLLCCorporationLimited Partnership

   State/Province:

7. Years in Business: Years Incorporated:
8. Have you ever filed for bankruptcy? YesNo
9. Type of Location: MobileLock ShopOther
   Other?
10. Tax Exemption Number: Massachusetts Businesses, send copy of Mass Sales Tax Resale Certificate Form ST-4
11. Is this business affiliated with or part of another business that is now a customer? YesNo



If so, give details

If partnership or sole proprietorship, identify all principals using additional sheets if necessary. If a corporation, identify the President, Treasurer and Secretary and note titles accordingly.

12. Principals/Corporate Officers:
    
    
    Principal's name: Title:
    
    Home Address:
    RentOwn Property in name of: Phone #:
    
    
    Principal's name: Title:
    
    Home Address:
    
    RentOwn Property in name of: Phone #:
    
    
    Principal's name: Title:
    
    Home Address:
    
    RentOwn Property in name of: Phone #:
    
    
13. Trade References: (Note: Include Fax Number to speed approval of your application)
    
    
    Name:
    
    Address:
    
    Contact Name:
    
    Phone #: Fax #:
    
    
    Name:
    
    Address:
    
    Contact Name:
    
    Phone #: Fax #:
    
    
    
    Name:
    
    Address:
    
    Contact Name:
    
    Phone #: Fax #:
    




14. Bank References:
    
    
    Name of Bank:
    
    Bank address:
    
    Contact Name: Phone #:
    
    Type of account: Account #:
    
    
    Name of Bank:
    
    Bank address:
    
    Contact Name: Phone #:
    
    Type of account: Account #:
    
    
15. Accounts Payable Contacts:

This information has been given for the purposes of obtaining credit and is certified and warranted to be true. I/We agree also that STONE & BERG may request further credit information about me/us from a credit reporting agency at any time. I/We agree that STONE & BERG may provide credit information to others without prior consent.

16. I/We authorize the following individuals to charge goods purchased from you to my/our account:









I/We may change the authorized individuals from time to time by written notice to you at the address where payments are sent.

^(*)Required: Please type in necessary signature responses. Stone & Berg will mail forms back for signature of these individuals designated upon receipt by Stone & Berg of completed and signed application and terms and guarantee. Account will be opened when approved by credit department.