Credit Application And Agreement Confidential

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CREDIT APPLICATION and AGREEMENT

CONFIDENTIAL

CUSTOMER ACCOUNT INFORMATION

This Credit Application covers all Company Owned Locations

* New Outlet/Customer Number

IMPORTANT: If this application is for an additional location under the same Corporation for which a charge

account exists, complete only the General Information, Headquarters address, and Signature Sections.

GENERAL INFORMATION

Please PRINT * Indicates required fields

* Corporate Name (Legal Name)

Trade Name (DBA Name)

* State of Incorporation

Federal ID Number

Existing Outlet number (s)

HEADQUARTERS ADDRESS

ACCOUNTS PAYABLE INFORMATION

* Name

* Manager of A/P

Phone number

* Address

E-mail Address

Fax number

* City

Zip Code

Other A/P Contact

State

* Main Phone Number

E-mail Address

STATEMENT ADDRESS (BILL TO) IF DIFFERENT THAN HQ ADDRESS

Name

Address Line 1

Address Line 2

City

State

Zip Code

BUSINESS INFORMATION

Type of Business:

Line of Business:

Vending

Restaurant

Retail

Corporation

Proprietorship

Distributor

Convenience

Partnership

L.L.C.

Other (explain)

Wholesaler

Entertainment

* Month / Year Business Was Established:

Lodging

Grocer

* Estimated Monthly Beverage Purchases:

COMPLETE THE FOLLOWING FOR COMPANY PRINCIPALS

* President/Owner

Vice President

Chief Financial Officer

Other Officer

BANK and TRADE REFERENCE INFORMATION

* Bank Name / Contact

* Account Number

Fax Number

Bank Address

City

State

* Phone Number

Trade Reference Name

Account Number

City

State

Phone Number

SALES REPRESENTATIVE INFORMATION

Sales Rep Name

Sales Rep Phone Number and/or E-mail

LEGAL RIGHTS STATEMENT

If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact

Credit Department, 521 Lake Kathy Dr, Brandon, FL 33510 (813) 569-2600 within 60 days from the date you are notified of our decision. We will send you a written

statement of the reasons for the denial within 30 days of receiving your request for the statement. NOTICE: The Federal Equal Credit Opportunity Act prohibits

creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the

capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in

good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning the creditor is the

Federal Trade Commission, Equal Credit Opportunity, Washington, DC 20580

**To expedite processing please attach a copy of the first page of your most recent bank account statement**

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