Nutrin Distribution Company
P.O. Box 65597, Washington, DC 20035
Tel: 1-877-2Nutrin   Fax:  1-815-301-9184

Credit Application:

ATT: Credit Dept  

MAIL:

Nutrin Distribution Co./ Credit Dept
P.O. Box 65048, 
Washington, DC 20035

Legal Name of Organization___________________________________

Name of Officer Requesting Credit: __________________________________

SHIPPING INFORMATION:

Shipping Address (Street 1)___________________________________

Shipping Address (Street 2)___________________________________

Shipping Address (City)___________________________________

Shipping Address (State of Province)____________________________

Shipping Address (ZIP or Postal Code)_________________________________

Shipping Address (Country)____________________________

Telephone Number _________________________

Fax Number ______________________________

Email Address (Optional) ______________________

Contact Person _________________________________

BILLING INFORMATION:

Billing Address (Street 1)_________________________________

Billing Address (Street 2)_________________________________

Billing Address (City)_________________________________

Billing Address (State)_________________________________

Billing Address (ZIP or Postal Code)_____________________________

Shipping Address (Country)

Telephone Number _________________________

Fax Number ______________________________

Email Address (Optional) ______________________

Contact Person _________________________________

Doing Business As ___________________________________________

Tax ID # ___________________________________

Type of Organization

Corporation

Not-For-Profit

Sole Proprietorship

Individual

Partnership

Limited Liability Company

Years in Business ____

State or Country where organized ________________

Dun & Bradstreet # _____________

How much credit does your company wish to establish? $____________

Is the company listed on a public exchange? (Yes/No) If yes, Symbol: _____

Gross Sales of company in last tax year: ______________

Taxable Income of company in last tax year: _____________

Note: Because it ties up excessive capital, Nutrin cannot Prepay and Add

freight charges. Nutrin offers shipping via Freight Collect with your preferred

carrier, or at your company's option, Nutrin can ship freight collect via its

own freight broker who can normally arrange shipments at a very competitive

rate. If your company wishes to use this form of shipment, Nutrin will submit

this credit application to the freight brokerage for its own independent

evaluation and if credit is given by the freight brokerage Nutrin can ship via

freight collect using that freight brokerage company.

Small print:

Nutrin accepts no liability or responsibility for any decision by any freight

brokerage company to extend or not extend credit, and accepts no liability

whatsoever for any omission or failure on the part of freight brokerage company.

Name of preferred freight company ________________________

Your account number with preferred freight carrier __________________

Do you wish Nutrin to submit this credit application to freight brokerage

company? (Yes / No)

PRIMARY BANK INFORMATION (Bank where checking account is maintained):

Name of Bank:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

SECONDARY BANK INFORMATION (Bank where your company has loans outstanding):

Name of Bank:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

TRADE REFERENCE INFORMATION: 1-5

Name of Reference:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

Name of Reference:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

Name of Reference:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

Name of Reference:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

Name of Reference:____________________________________

Street Address:__________________________________

Street Address:__________________________________

City:_________________________

State or Province:__________________

ZIP or Postal Code:_________________

Telephone Number:___________________

Name of Contact Person Familiar with Account:____________________________

Account Number:_______________________________

Years Account Active:__________

Nutrin Corporation, P.O. Box 65048, Washington, DC 20035
Toll Free (888) 718 3235     FAX (815) 550 6246