Company Name:__________________________________________________________________________________________

Mailing/Billing Address: ____________________________________________________________________________________

_______________________________________________________________________________________________________

Shipping Address:________________________________________________________________________________________

_______________________________________________________________________________________________________

Telephone: ___________________________________________    Fax:_____________________________________________

Please check all purchasing options that are accepted/used by your company:

Federal ID No./SS No.: _________________________________  Dun & Bradstreet No.:__________________________________

Sales Tax No.:__________________________________

Date Business Established: ____________  Total Number of Employees:____________

President:________________________________________________________

Vice President:___________________________________________________

Buyer: _________________________________________________________

Controller:_______________________________________________________

Accounts Payable Contact: _________________________________________

Accounts Payable Fax:______________________________________

Name of Financial Institution:_________________________________________________________________________________

Address:________________________________________________________________________________________________

_______________________________________________________________________________________________________

Telephone: ___________________________________________    Fax:_____________________________________________

Name of Business Reference (DO NOT USE PLASTIC RESIN SUPPLIER):_________________________________________

Address:_______________________________________________________________________________________________

_______________________________________________________________________________________________________

Telephone: ___________________________________________    Fax:_____________________________________________

Name of Business Reference (DO NOT USE PLASTIC RESIN SUPPLIER):_________________________________________

Address:_______________________________________________________________________________________________

_______________________________________________________________________________________________________

Telephone: ___________________________________________    Fax:_____________________________________________

Name of Business Reference (DO NOT USE PLASTIC RESIN SUPPLIER):_________________________________________

Address:_______________________________________________________________________________________________

______________________________________________________________________________________________________

Telephone: ___________________________________________    Fax:____________________________________________

By signing this form, you are agreeing to comply with the terms and conditions as set forth by Plastic Services & Equipment. The information you have provided above will be used by us to assess your credit. Under open account terms, all purchases are subject to credit approval and are due and payable, in U.S. funds, within 30 days from the date of invoice. A finance charge of 2% per month (24% per annum) plus attorney fees and all costs associated with collection will be added to all past due accounts. We reserve the right to deny open account terms to any company.