DISTRIBUTOR ACCOUNT APPLICATION

Company Name

Year Incorporated

Principal

Tel

(###)

###

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Fax

(###)

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Contact

(###)

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Billing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Federal/Tax ID #

Resale #

Accounts Payable Email

Accounts Payable Contact #

(###)

###

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Accounts Payable Phone #

(###)

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Type of Business :

Corporation

Partnership

Individual

Approximate Annual Sales

Credit Line Requested

* If you are tax exempt, provide certificate or sales will be taxed. A resale certificate is required, No exceptions.

BUSINESS TRADE REFERENCES

* Email of Fax number must be provided to process the credit inquiry.

Company Name 1

Account #

Contact

(###)

###

####

Tel #

(###)

###

####

Fax #

(###)

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Company Name 2

Account #

Contact

(###)

###

####

Tel #

(###)

###

####

Fax #

(###)

###

####

Company Name 3

Account #

Contact

(###)

###

####

Tel #

(###)

###

####

Fax #

(###)

###

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Radio

Option One

Option Two

Select

BANK REFERENCES

Name

First Name

Last Name

Tel

(###)

###

####

Fax

(###)

###

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Contact

(###)

###

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Account #

I authorize the above references and bank to release relevant credit information to UTOPIA LIGHTING, Inc.

Name

First Name

Last Name

Title

Date

YYYY

We reserve the right to add to your monthly balance, a service change of 1/12% per month (18% annual rate) on all amounts unpaid on the first day of the 2nd month following purchase. If this account is placed with a third party for collection, buyer agrees to pay all costs and expenses of collection including the reasonable attorneys fees in addition to the service charges stated above.

PLEASE MAIL THE ORIGINAL SIGNED APPLICATION AND FAX RESALE PERMIT & COPY TO : (310) 327-5711

Credit Application

CREDIT APPLICATION