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DISTRIBUTOR CREDIT APPLICATION COMPANY NAME: TELEPHONE: FAX: LOCATION ADDRESS: CITY: STATE: ZIP BILLING ADDRESS: CITY: STATE: ZIP FEDERAL ID NUMBER: D & B NO. AND RATING: YEAR STARTED: RESALE CERTIFICATE NO. PRINCIPALS NAMES CORPORATION TYPE: CORP PARTNERSHIP LLC PROPRIETORSHIP ACCOUNTS PAYABLE CONTACT: A/PAYABLE PHONE: FAX: EMAIL Trade References 1) Company Name & Address Phone Contact 2) Company Name & Address Phone Contact 3) Company Name & Address Phone Contact PRIMARY BANK NAME: CITY: STATE: ZIP: ( ) ( ) PHONE: FAX: ACCOUNT #: TYPE: BANK OFFICER: The above information is submitted for the purposes of obtaining credit with R&R TIRE SURFACE PROTECTORS, INC.. The undersigned authoriz-es you to make such are necessary to obtain credit information and authorize my bank, suppliers, and credit references to release information in my accounts. SIGNATURE PRINTED NAME AND TITLE DATE Please Fax Your Completed Application to: 970-226-4991