Ortco Incorporated

Application For Credit

Name Of Company___________________________________________________________________

Billing Address_____________________________________ City / State / Zip___________________

Shipping Address___________________________________ City / State / Zip___________________

Telephone Number__________________________________ Fax Number______________________

Name Of President / Owner____________________________________________________________

Year Business Started________ Tax Status_____ Taxable______ Non-Taxable (Attach Certificate)

References: (Please Be Sure To Include Fax Numbers)

Bank Name:____________________________ Contact:_____________________________________

Telephone#:____________________________ Fax #:_______________________________________

Trade References:

1. Name:____________________________ Telephone#:_______________ Fax #:________________

2. Name:____________________________ Telephone#:_______________ Fax #:________________

3. Name:____________________________ Telephone#:_______________ Fax #:________________

All debts owed by customer are due within 30 days after the date of the invoice. The undersigned states
that they have the authority to bind the applicant to this agreement, and hereby authorizes any and all
companies and financial institutions to release applicant's credit information to Ortco Incorporated.

Signature of Representative of Firm:_____________________________________________________

Title:_______________________________________________________________________________

P.O. Box 94127 · Oklahoma City, Oklahoma 73143-4127 ·  Phone 405-670-2803 ·  1-800-654-4891 ·  Fax 405-672-5681