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CUSTOMER INFORMATION

COMPANY NAME ________________________________________________________________ ADDRESS ______________________________________________City  _____________________ STATE ____________ZIP CODE ___________________PHONE ____________________________ CONTACT _____________________________________FAX _______________________________ OWNERSHIP: ____ CORPORATION ____ PARTNERSHIP ____ SOLE PROPRIETORSHIP

____ SUBSIDIARY-PARENT COMPANY ______________________________ CORPORATE OFFICER'S NAME ______________________________Tittle _____________________            FEDERAL TAX ID __________________________DUNS ______________________YEAR EST. _______

BANK REFERENCE

BANK NAME ____________________________________________ACCOUNT # _______________ CITY _______________________CONTACT ___________________PHONE ___________________ BRANCH ___________________CUSTOMER SINCE____________FAX ______________________

REFERENCES

COMPANY NAME ________________________________________PHONE ___________________ CONTACT ______________________________________________FAX ______________________ ADDRESS ________________________________________________________________________

COMPANY NAME ________________________________________PHONE ___________________ CONTACT ______________________________________________FAX ______________________ ADDRESS ________________________________________________________________________

COMPANY NAME ________________________________________PHONE ___________________ CONTACT ______________________________________________FAX ______________________ ADDRESS ________________________________________________________________________

____________________________________ NAME

____________________________________ SIGNATURE

____________________________________ TITLE

____________________________________ DATE

This information will be used solely for the purpose of knowing our customers and comply with "know your customers" laws.

Please save this form on your computer, and send it via email to cs@printers-toners.com

ALL INFORMATION WILL REMAIN CONFIDENTIAL

OFFICE 302-360-8443

cs@printers-toners.com

www.cellnet-usa.com

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