880 w. 1st LA, CA 90012

VENDOR INFORMATION

Name: _____________________________________________________

Address: ___________________________________________________

City:______________________________ State: _____ Zip: _______

Phone:___________________

Time in Business: _____years

Corporation: _________ Partnership: _________ Proprietorship:________

Equipment Sold: ______________________________________________

Authorized Dealer: _____Yes _____No Brand ________________

Fed Tax ID#:_________________ Resale Certificate#: _______________

PRINCIPAL(S) INFORMATION(S)

Name: ________________________ Name: ______________________

Address: ______________________ Address:_____________________

City/ST/Zip: ___________________ City/ST/Zip: __________________

S/S NO.:______________________ S/S NO.:____________________

Title/%Own: ____________________ Title/%Own:__________________

BUSINESS FINANCIAL RELATIONSHIP

Bank Name: _____________________ Telephone#: __________________

Account#:_______________________ Officer :______________________

TRADES/MANUFACTURES OF EQUIPMENT SOLD

Name: ________________________ Name: ________________________

Phone: ________________________ Phone: ________________________

Contact: _______________________Contact: _______________________

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____________________________________________________________

Signature: _______________________ Date: _______________________