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INTERNATIONAL, INC.

1220 SPRING GARDEN STREET

NEW ACCOUNT APPLICATION:

PLEASE COMPLETE THIS PAGE AND SEND WITH ORDER FORM

LEGAL BUSINESS NAME: _______________________________________________EMAIL:_______________________________

TRADING NAME: _______________________________________________________PHONE#(_____)______________________

STREET ADDRESS: (Summer) (Winter)_________________________________________________________________________

CITY: ____________________________________STATE: ____ ZIP: _________-______FAX#(_____)______________________

STREET ADDRESS: (Summer) (Winter)_________________________________________________________________________

CITY: ____________________________________STATE: ____ ZIP: _________-______FAX#(_____)______________________

YEARS IN BUSINESS: __________KIND OF BUSINESS: _________________________________________________________

BANK REFERENCE: __________________________________________________ACCT. NUMBER________________________

BANK ADDRESS: _________________________________________________________STATE: ____ ZIP: _________-_______

MARK ONE: (1) ____PROPRIETORSHIP (2) ____PARTNERSHIP (3) STATE OF INCORPORATION ______YEAR _________

OFFICERS, PARTNERS, OR PRINCIPALS

1. NAME__________________________________________ POSITION ______________________ SS#_____________________

HOME ADDRESS: _______________________________________________________ HOME TEL# (_____)__________________

2. NAME__________________________________________ POSITION ______________________ SS#_____________________

HOME ADDRESS: _______________________________________________________ HOME TEL# (_____)__________________

3. NAME__________________________________________ POSITION ______________________ SS#_____________________

HOME ADDRESS: _______________________________________________________ HOME TEL# (_____)__________________

4. NAME__________________________________________ POSITION ______________________ SS#_____________________

HOME ADDRESS: _______________________________________________________ HOME TEL# (_____)__________________

REFERENCES: (GIVE ONLY NAMES OF SUPPLIERS GRANTING YOU AN OPEN ACCOUNT)

1. NAME__________________________________________ TEL# (_____)________________ FAX#(_____)__________________

STREET ADDR.: _________________________________________ CITY: _________________________ST ____ZIP __________

2. NAME__________________________________________ TEL# (_____)________________ FAX#(_____)__________________

STREET ADDR.: _________________________________________ CITY: _________________________ST ____ZIP __________

3. NAME__________________________________________ TEL# (_____)________________ FAX#(_____)__________________

STREET ADDR.: _________________________________________ CITY: _________________________ST ____ZIP __________

4. NAME__________________________________________ TEL# (_____)________________ FAX#(_____)__________________

STREET ADDR.: _________________________________________ CITY: _________________________ST ____ZIP __________

THE ABOVE STATEMENT OF INFORMATION IS MADE FOR THE PURPOSE OF OBTAINING MERCHANDISE FROM THE SELLER ON CREDIT, AND THIS CERTIFIES THAT THE SELLER SHOULD RELY ON SAME AS CORRECT. PERMISSION IS GRANTED TO CONTACT THE ABOVE REFERENCES FOR ANY CREDIT INFORMAITON THAT IS DESIRED.

1/WE AGREE TO THE TERMS OF PAYMENT MENTIONED ON SELLER’S ORDER FORM AND INVOICE INCLUDING THE PROVISION FOR SERVICE CHARGES AND COSTS FOR LATE PAYMENT ACCORDING TO STATE LAWS WHERE THE SELLER HAS ITS WAREHOUSE OR REGISTERED OFFICE. I UNTERSTAND ESTABLISHING CREDIT IS A PRIVILEDGE AND REFERENCES MUST BE CHECKED, UNTIL CREDIT TERMS ARE ESTABLISHED, I (___) AUTHORIZE / (___) DO NOT AUTHORIZE SELLER TO SHIP MERCHANDISE “C.O.D.” WITH PAYMENT TO BE MADE BY CASH OR CERTIFIED CHECK.

SIGNED: ___________________________________ BY: _____________________________DATE:__________________

SIGNATURE OF AUTHORIZED AGENT PRINTED NAME AND TITLE

IN LIEU OF A FINANCIAL STATEMENT AND AS AN INDUCEMENT TO SELL MERCHANDISE TO THE BUYER, THE PRINCIPALS, OWNERS, OFFICERS OR PARTNERS MAY SIGN THE FOLLOWING ASSUMPTION OF RESPONSIBILITY AND GUARANTY AGREEMENT. IF FIRM IS A PROPRIETORSHIP AND PRINCIPAL IS MARRIED, BOTH SPOUSES MUST SIGN.

I/WE ASSUME PERSONAL RESPONSIBILITY FOR AND GUARANTEE PAYMENT OF ALL SUMS DUE AND PAYABLE TO SEAGULL INTERNATIONAL INC. T/1 SEGAL INTERNATIONAL BY THE BUYER LISTED ABOVE, INCLUDING SERVICE CHARGES AND FEES THAT MAY ACCRUE IN COLLECTIN THE ACCOUNT.

SIGNED: ______________________________________ PRINT: ______________________________DATE:__________________

1220 Spring Garden Street • Philadelphia, PA 19123 • Tel: 800-666-9300 • Fax: 215-922-0970

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