3927 Moreland Ave. (Hwy 42) Conley, GA 30288 Main: (404) 362-9210 Fax: (404)362-9236

COMPANY INFORMATION

Full Legal Business Name:

Doing Business as or also known as:

Phone: Fax: E-mail:

Dunn & Bradstreet #:

Address (Not P.O. Box):

City: State: ZIP Code:

Bil ling Contact Name: Bil ling Phone: Bil ling Fax:

Officers Name:

Home Address:

City: State: ZIP Code:

Social Security Number:

Home Phone:

Cell Phone:

Corporation ( ) Partnership ( ) Proprietorship ( )

BUSINESS DESCRIPTION

Please describe the nature of your business:

BUSINESS CREDIT INFORMATION:

Taxpayer I.D. Number: In Business Since: No. Of Employees: Company Annual Revenue:

BUSINESS/TRADE REFERENCES

Company Name:

Address:

City: State: ZIP Code:

Phone: Fax: E-mail:

Type of account:

Company Name:

Address:

City: State: ZIP Code:

Phone: Fax: E-mail:

Type of account:

Company Name:

Address:

City: State: ZIP Code:

Phone: Fax: E-mail:

Type of account:

BANK REFERENCE:

Bank Name:

Checking Account #:

Phone:

I/W e certify that all information is true and complete. This request is for DST charge account. I/W e authorize DST to obtain further information

concerning credit and f inancial condition of the corporation, principal owners, proprietors or partne rs; and to exchange or provide information with other credit grantors. I/W e agree to pay the amount invoiced in full and wil l provide DST a separate f inancial statement upon request. In the event

DST extends credit to the applicant, then the applicant agrees that DST may assess interest and service charges on purchaser’s outstanding account balance at a rate of 2.5% per month (18% annum). The purchaser further agrees to pay all costs of collection, including a 15% attorney’s fee in the event the applicant’s account is turned over to an attorney. It is agreed that this agreement wil l be governed under the law of the State

of Georgia. DST has the option of pursuing an action under this agreement in any court of competent jurisdiction in the State of Georgia and the customer consents to venue and jurisdiction in the State of Georgia. It is agreed that seller shall retain tit le to any goods sold unti l payment in full has been received by seller. If my (our) business is a corporation, I (we) agree to be personally responsible as guarantor for any purchases made by the corporation.

Authorized Signature:

Please Print Name:

Date:

Duval Semi Trailers (DST)