Company Name:    

        Physical Address:  

                          City:          State:          Zip:     -

          Billing Address:    

                          City:          State:          Zip:     -

                       Phone:     --                             Fax:     --  

      Email Address:    Web Site: 

               How many years has this company been in business?     <select> 1 2 3 4 5 6 7 8 9 10+

               State of Incorporation:    

             Name and Title of Owners or Officers:    

Type of Entity:      Corporation   S-Corporation   Partnership  Sole-Proprietorship

____________________________________________________________________________

NAME:      ACCT# 

Address:

City:             State:          Zip:     -

Phone:     --   Person to Contact:  

____________________________________________________________________________

NAME:      ACCT# 

Address:

City:             State:          Zip:     -

Phone:     --   Person to Contact:  

____________________________________________________________________________

NAME:      ACCT# 

Address:

City:             State:          Zip:     -

Phone:     --   Person to Contact:  

____________________________________________________________________________

BANK REFERENCE:

   NAME:      ACCT# 

       Address:

       City:             State:          Zip:     -

         Phone:     --   Person to Contact:  

                      TAX ID#:     Failure to provide tax exempt certificates

                                                                        will result in taxes being assessed.

Terms: Net 10 days. Accounts not paid upon net due date may be charged one and one-half (1.5) percent per month, which is an annual rate of eighteen (18) percent, of the highest rate permitted by law.  The customer is responsible for all return check charges and incurred collection costs or fees.

The undersigned agrees and authorizes BannerElk Trading Company, and/or its subsidiaries to obtain credit

information about the undersigned from time to time (for example, by requesting a credit report or contacting

bank and trade references) as may be required.  Products will not be shipped until the required information has

been received.  The above information and any information provided is confidential and for the use of BannerElk

Trading Company, its subsidiaries, affiliates, successors and assigns.

SIGNATURE: ______________________________TITLE: ______________________DATE: ____________

(signature required on faxed or mailed copies)

Do you accept the terms and conditions as stated above?  Please type YES or NO 

Submitted by:  LAST NAME FIRST NAME

THANK YOU FOR SUBMITTING. 

UPON APPROVAL, AN ACCOUNT NUMBER WILL BE ISSUED WITHIN 3 BUSINESS DAYS.