S & S FUSION, INC.                                                                                   

PO BOX 175

HOOPER, UTAH 84315

(801) 971-9929

FAX (801) 731-1504       

APPLICATION FOR CREDIT

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Company Name_________________________________________________________________________________________________________________________________________

Physical Address_______________________________________________________________________________________________________________________________________

Billing Address_________________________________________________________________________________________________________________________________________

Phone Number_____________________________________ Fax Number_____________________________________ Email Address________________________________________

Business Type (Corporation, LLC, etc…) ___________________________________________________________Tax ID Number____________________________________________

Years in Business____________     Tax Exempt :  Yes  /   No    (If Yes, please attach Sales Tax Exemption Certificate)    Tax Exempt Number & State_______________________

 PO Required:   Yes  /  No

Owners and/or Company Officers

Officer/Title___________________________________________________________________ Social Security_________________________________ DOB______________________

Address_______________________________________________________________________________________________________________________________________________

Officer/Title___________________________________________________________________ Social Security_________________________________ DOB______________________

Address_______________________________________________________________________________________________________________________________________________

Officer/Title___________________________________________________________________ Social Security_________________________________ DOB______________________

Address_______________________________________________________________________________________________________________________________________________

References

Business Name__________________________________________________________________________________________________ Phone Number___________________________

Address________________________________________________________________________________________________________ Fax Number_____________________________

Business Name__________________________________________________________________________________________________ Phone Number___________________________

Address________________________________________________________________________________________________________ Fax Number_____________________________

Business Name__________________________________________________________________________________________________ Phone Number___________________________

Address________________________________________________________________________________________________________ Fax Number_____________________________

Bank Information

Bank Name______________________________________________________________________________________________________________________________________________

Branch Address_________________________________________________________________________________________________________________________________________

Phone Number_________________________________________________________________________________________________________Accounts:  Checking   and/or   Savings

Account Number(s)______________________________________________________________________________________________________________________________________

Terms

The undersigned is authorized to enter into this agreement as an Agent for­­­__________________________________________________. All of the invoices are due in full 30

days from the dates of the invoices unless otherwise agreed to in writing. A 1.5% per month (18% annually) interest change will be added to all accounts not paid within

30 days after due date. Those signing below warrant that they are authorized to enter into this Agreement, and are acting pursuant to a resolution of their respective

bounds of directors, if such resolution is required, prior to entering into such agreement.

________________________________________ agrees to be liable for a collection fee of 52% of the balance due if account is referred to an outside agency for collection.

________________________________________ also agrees to pay reasonable attorney’s fees and court costs incurred in the collection of balance due with or without suit.

Any changes of the terms of the terms of this agreement must be in writing. Any returned checks will be charged the maximum amount allowed by law.

Signature_______________________________________________________________________________________________________________________Date____________________

Print Name__________________________________________________________________________Title________________________________________________________________