HOLLAND P U M P

Application for Credit

Legal Business Name _______________ _ Date ________ _

Type of Business: _____ Corporation ______ Partnership _____ Individual

Date Business Established ________ _

Business Address ______________________________ _

City ______________ State, _________ Zip, ________ _

Mailing Address ______________________________ _

City ______________ State _______ ~Zip ________ _

Phone ( Main Fax ---'--__ -'--_____________ _

Main E-Mail Address ____________________________ _

Accounting E-Mail Address ___________ Accounting Fax ---'( __ --')'--_____ _

Purchasing E-Mail Address Purchasing Fax _L( __ .L) _____ _

Resale Tax # Federal ID # __________ _

Dun & Bradstreet # ___________ _

Do You Prefer Invoices I Statements E-Mailed __ _ Faxed __ U.S. Mail __

The following information is submitted as a basis for extension of credit by Holland Pump Company, the following must be completed in full.

Li st Owners, Partners, Officers, and lor primary stockholders (required):

Home Address

Desired Monthly Credit $, ___________ _

Three Trade References Supplier Name Address 77

377J-888-997-PUMP Toll Free' (9 12)466-0304 Telephone' (9 12)466-0086 Fax

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Telephone

HOLLAND P U M P

Bank References Name Of Bank _______________ Telephone ----'(~ __ )L--______ _

Address City State Zip, ___ _

Account Number Name of Bank Officer __________ _

Purchase Order Required? _Yes _No List people allowed to order and turn in equipment:

As a consideration for the extension of credit the undersigned agree to the following terms: All charges incurred during any month are due upon receipt of invoice, and in case payment is not made as specified, a

service charge of I 112% per month is authorized lO be added to the amount due Holland Pump Company. In the event it becomes necessary to place this account with an attorney for collection, the undersigned agree to pay all

cost of collection, including attorney's fees and hereby waive OUf privilege of being sued in the county of our residence and agree that suit may be brought in Palm Beach or Orange County, Florida USA,

Should Holland Pump Mfg" inc, ever, because of default, be obligated to institute any proceedings against the undersigned, we hereby waive any notice requirements.

Delivery of any goods by Holland Pump Company to the carrier at the shipping point shall constitute delivery to the buyer. Title to the goods shall not pass to the Buyer until the buyer has fully paid for the goods. Buyer shall do whatever is necessary to protect and preserve the goods in his possession at all times

IIWE CERTIFY THAT ALL THE INFORMATION ON THIS FORM IS CORRECT AND THAT IIWE FULLY UNDERSTAND YOUR CREDIT TERMS AND AGREE TO PROPER PAYMENT.

Authorized Signature Print name I Title Date

INDIVIDUAL PERSONAL GUARANTEE I, , residing at for and in consideration of your extending credit, at my request to, (hereby referred to as the "company"), of which I am (Tit le), do hereby personally guarantee to you the payment at in the State of of any obligation of the company and I hereby agree to bind myself to pay you on demand any sum which may be due to you by the Company whenever the Company shall fail to pay the same, It is understood that this guarantee shall be a continuing and irrevocable guaranty and indemnity for such indebtedness of the Company. I do hereby waive notice of default, non-payment and notice thereof and consent to any modification or renewal of the credit agreement hereby guaranteed. I understand that goods are being leased, rented and I or sold in Palm Beach County, Florida in reliance upon this guaranty and the obligations guarantied hereunder, including the proper care and redelivery of goods and of payment, arise in Palm Beach County, Florida.

Signature, ___________________ Social Security # _______________ _

Witness __________________ Address _________________ _

2610 Sidney Lanier Drive· Brunswick, Georgia 31525 1·888-997-PUMP Toll Free· (912)466-0304 Telephone· (9 12)466-0086 Fax

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