J.S. GREEN, LTD.
Consumer Products Division
4546 El Camino Real, Suite 258
Los Altos, CA 94022
jsgreenltd@sbcglobal.net

800 332-1622 TOLL FREE
650 949-1057 DIRECT
650 949-1864 FAX


APPLICATION FOR CREDIT


Date: _____________________ Amount requesting:$_________________



Company:__________________________________ Year Started:_________


Billing Address:
__________________________________________________


City: ________________________ State: __________ Zip Code: ________


Phone: ___________________ Fax: ___________________

Email: _____________________________

[ ] Corp. [ ] Partnership [ ] Proprietorship
[ ] Other: __________________



Principle Name(s),Title(s):_______________________________________

Phone number(s):______________________________________________


Accounts Payable Contact Name, Number:
________________________________________________________



Bank: _______________________________

Phone: __________________ Fax: ___________________

Account # ________________________________________




Current Credit Reference:


Company: ________________________________________

Contact: ____________________________


Phone: __________________________

Fax: ______________________________



Company: ________________________________________

Contact: ____________________________


Phone: __________________________

Fax: ______________________________




Company: ________________________________________

Contact: ____________________________


Phone: __________________________

Fax: ______________________________




With signing, you have read and agree to the terms of J.S. GREEN, LTD.


Signed by: _____________________


Print Name: _______________________