Street Address

City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Credit Limit Desired

Number Of Years In Business

Name 1

Address

Social Security #

Address

Social Security #

Type of Business

Are Purchase Orders Required? Yes No

Person In-Charge of Accounts Payable

Phone Number

Are You Tax Exempt? Yes No

If yes, attach a copy of your tax exempt certificate.

Tax Exempt Number

Name

Address

City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Phone Number

Fax Number

Address

City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Phone Number

Fax Number



Name

Address

City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Phone Number

Fax Number



Name

Address

City State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code

Phone Number

Fax Number

Bank Name and Branch

Phone Number and Contact



I understand and agree that account balances are due and payable in full on the terms of NET 30. Accounts not cleared will be put on C.O.D. basis.
Past due balances are subject to a 1 _ % monthly finance charge (annual percentage rate of %) or the maximum lawful rate.
A service charge of $25.00 will be assessed on returned checks.
I accept full responsibility of payment of the amounts due Northeast Air Solutions ,Inc. by the above named account and will personally make full payment of the amounts due on the 30th day following purchase if not paid bye the above named account on the due date.

Signature (Initials) Date

By submitting your initials you agree to all of the above.

Title