325 Rutherford Street Goleta CA 93117-3785 - Voice: (805) 964-8787 - Fax: (805) 964-1249

Last Name________________Middle__________First________________ Home Phone ______________
Home Address____________________________City_________________State/Zip_________________
Rent or Own______________________How Long___________________
Birth Date______________Social Securtiy #________________Driver License #___________________ Employer________________________________Address_______________________________________
Position Held__________________ How Long?__________________ Monthly Income_______________
Previous Employer _____________________________ How Long_________ Phone _________________

If you wish us to use your spouse's credit history in determining credit eligibility :
Spouse's Name______________________ Social Secruity:___________Drivers License#____________
Employer ___________________________Address____________________________________________
City________________________________State/Zip________________ Phone_____________________
Position Held_________________________How Long?_________ Monthly Income__________________
Previous Employer____________________ How Long?_________ Phone__________________________
Other Income and Source (Explain)_________________________________________________________


Name of Bank ______________________________________________ Branch _____________________
Address _________________________________ City ______________________ State/Zip __________
Checking Acct. # _______________ Savings Acct. # ______________
Money Market/Other__________

1. Company Name_________________________Account #________________Phone________________ Address_________________________________City______________________State/Zip_____________
2. Company Name_________________________Account #________________Phone________________ Address_________________________________City______________________State/Zip_____________
3. Company Name_________________________Account #________________Phone________________ Address_________________________________City______________________State/Zip_____________

Card Name (Visa, M/C, etc.)_________Account #_________________________Exp. Date_________

Who is authorized to sign on your account?___________________________________________________
Do You Use Purchase Orders? ____________Job Names? ____________ Resale #?__________________

By signing, I (we) ask that an account be opened for myself/company. In the event an account is opened
for myself/company, I (we) agree to the following terms and conditions:

1. INVOICE TERMS: Net 30 Days.
2. LATE CHARGES: 1.5% per month or maximum allowable rate. Minimum of $.50 per month.
3. ACCELERATION CLAUSE: If the account becomes delinquent, creditor reserves the right to accelerate and
demand payment of the balance in full, together with all accrued interest, late charges and costs of collection.
4. COLLECTION FEES: In the event of default, I (we) agree to pay all reasonable attorney's fees and/or costs
incurred by creditor to collect all amounts due.
5. AUTHORIZED BUYERS: I (we) agree to be responsible for all purchases made to this account by the
authorized buyers above named and subsequently authorized by us unless I (we) have notified you/creditor
in writing, that said parties are no longer authorized to charge to said account.
6. AUTHORIZATION TO CHECK CREDIT HISTORY: It is understood that an investigation of my references and
credit history will be conducted, including information from the credit reporting agencies.

Date_______Applicant Signature ____________________Date _______CoApplicantSignature_____________