Credit Application (Please Print and Fax It Back)

Company Information

Name:________________________________________________________________________

Address:______________________________________________________________________

City:_____________________________________________ State:____________

Zip:__________________

Phone:(          )________-______________________

Fax:(          )________-________________________

Line of Business:_________________________________________

No. of Employees:_________________

Description of Goods Sold:__________________________________________________________________

Resale Certificate No.:________________________________

Year Bus. Started:_____________________

(Please attach a copy of your resale certificate)

Type of Business:____ Corporation          ____ Sole Owner        ____Partnership


Business Information

Name of Officer                                                                                 Title % of Stock

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

Bank References

Name: __________________________________  Name:_______________________________

Phone:(               )________-________________________

Phone:(               )________-________________________

Acct.#:_________________________________

Acct.#:_________________________________

Business References

Name & Address                                                                           Phone / Fax .

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

I, ______________________________________ am authorized to give my permission for Ontime Circuits, Inc.to receive banking information to establish a line of credit for our company.

                                                              X______________________________
                                                                                     Authorized Signature

                                                                                 Title ___________________________