BUSINESS CONTACT INFORMATION
Contact Name:	Title:
Company Name:
Phone:	Fax:	E-mail:
Address:
City:	State:	ZIP Code:
Years in business:	Business type:

BUSINESS AND CREDIT INFORMATION
Bank name:	Contact:
Bank address:	Phone:
City:	State:	ZIP Code:
Bank account number:
Credit card type:	Account number:	Expiration date:
Name on card:	Billing address:	ZIP Code:

BUSINESS/TRADE REFERENCES
Reference #1:
Company name:	Address:
City:	State:	ZIP Code:
Phone:	Fax:	E-mail:
Type of account:
Reference #2:
Company name:	Address:
City:	State:	ZIP Code:
Phone:	Fax:	E-mail:
Type of account:
Reference #3:
Company name:	Address:
City:	State:	ZIP Code:
Phone:	Fax:	E-mail:
Type of account:

AGREEMENT

All invoices are to be paid 30 days from the date of the invoice.
By submitting this application, you authorize Kerick Valve, Inc. to make inquiries into the banking and business/trade references that you have supplied and authorize them to release your business and trade account information to us.
Past due amounts will be charged to the credit card on file. Late payments are subject to a 1.5% service charge per month plus all cost of collection including reasonable attorney fees. You agree that the laws of the state of Florida will apply and venue for any action will be Duval County, Florida.

Personal Guarantee

I __________________________________________, in consideration for implementation of this agreement to the above described applicant, do hereby individually and unconditionally guarantee the payment of any sums that may become due to Kerick Valve, Inc. relating from any extension of credit or trade account.

SIGNATURES
Title: Date:	Title: Date:

Fax completed form to: (904) 732-2259 Call (904) 732-2258 or e-mail rock@floatvalve.com with any questions.