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Application for 30 Day Credit

SUBMITTED TO:      ADDRESS:CITY:STATE:ZIP:

CENTRI COATINGS & SYSTEMS CORP    1010 Gentry      NKC     MO  64116       

Name of Firm (Buyer):

Street Address or PO Box Number:

CityState:Zip Code:

Name, Title, and Phone Number of individual to contact regarding accounts payable:

Sales Tax Exempt?

Type of Organization:

Number of years business has been established:

Number of years at present location:

Bank Reference: State       Phone Number (with area code)

Account Number:

Trade References:

CompanyPhone Number (with area code)

CompanyPhone Number (with area code)

CompanyPhone Number (with area code)

-State-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiannaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

NoYes

-pick one-Profit CorporationNon-Profit CorporationPartnershipProprietorship

-pick one-NewLess than 3 years3 to 10 yearsMore than 10 years

-pick one-NewLess than 3 years3 to 10 yearsMore than 10 years

-State-AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiannaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming