Ship To:

Company Name:

Addrerss:

City:

State/Province:

Zip:

Bill To:

Company Name:

Addrerss:

City:

State/Province:

Zip:

Phone Number:

Fax:

*E-Mail Address:

*Accounts Payable Contact:

*Social Security #:

*or Federal ID #:

Choose One::

Sole Proprietorship:

Partnership:

Corporation:

Business In State Of

Number of Years In Business:

 Credit Date (Must Be Completed)

Bank Name:

Bank Address:

Bank City:

Bank State:

Bank Zip Code:

Bank Contact:

Bank Telephone:

Bank Account #:

Please List All Officers Of The Company, Owners or Partners Below

Name:

Address:

City:

State:

Zip Code:

Telephone:

Name:

Address:

City:

State:

Zip Code:

Telephone:

Trade References (Please include at least 1 equipment or part reference)

Ref1 Name:

Ref1 Address:

Ref1 City:

Ref1 State:

Ref1 Zip Code:

Ref1 Contact:

Ref1 Telephone:

Ref1 Account #:

Ref2 Name:

Ref2 Address:

Ref2 City:

Ref2 State:

Ref2 Zip Code:

Ref2 Contact:

Ref2 Telephone:

Ref2 Account #:

Ref3 Name:

Ref Address:

Ref3 City:

Ref3 State:

Ref3 Zip Code:

Ref3 Contact:

Ref3 Telephone:

Ref3 Account #:

I, We, the undersigned, being the owner, or principal stockholder of the entity, known as  , who have made application for credit with you, hereby agree for valuable consideration to unconditionally indemnify you from any and all losses, you might sustain by reason of the entity mentioned above failed to pay its obligations when due for goods and/or services delivered by you, sold by you and/or for work performed by you, and I, we, do agree to waive notice of default, hereby giving you the right to extend the time of payment without limitation and do individually and severally agree to be personally liable for the obligations of and/or for any goods, services and/or merchandise or credit extended/expended by you. The undersigned hereby authorizes D&S Vending,Inc. to investigate the credit of the entity and/or the individual submitting this document with any of its suppliers, financial institutions, credit bureaus, or credit reporting agencies and to retain this data in our file for future reference.

Date:

Name of Submitter of Guarantor:

Social Securty No:

By checking this box you are electronically signing this document.