Last   M. Init.   First

Title (Mr, Mrs, Dr)

Name of Business    Tax ID

Address

City           State   Zip/Postal

Phone     (Business)          Fax Req'd

Type of Business          

In Business Since         

Business Legal Name   

Legal Formation          Corporation  Partnership  Proprietorship  

Person Responsible for Transactions

Address

City           State   Zip/Postal

Phone     (Pers Responsible)    Cell Phone

Institution Name  

Checking Acct#    

Address

City           State   Zip/Postal

Phone     (Bank)    Fax

Institution Name  

Checking Acct#    

Address

City           State   Zip/Postal

Phone     (Bank)    Fax

Company Name

Contact Name    

Address

City           State   Zip/Postal

Phone     (Bank)    Fax

Acct Open Since (Year)   Credit Limit    Balance

Company Name

Contact Name    

Address

City           State   Zip/Postal

Phone     (Bank)    Fax

Acct Open Since (Year)   Credit Limit    Balance

Amount of Credit Requested

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein. Debtor agrees, in the event of default, to pay all expenses, including attorney fees, which are incurred or paid by Glove Nation, Inc.