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Not a signed up with us yet? Simply fill out the form below and we'll contact you shortly. * (If requesting a line of credit all * (starred) sections must be filled out. If not, and you'd like to prepay with your orders, just fill out the basic info.

* DBA:* Street Address* State* Zip Code* Phone Number* Additional Contact Name

* Legal Business Name:* City* County* Contact NameEmail and/or Fax* Add. Phone Number

Additional Locations

Street Address, City, State, ZipPhone Number

EmailContact Name

Business Information

Type of BusinessCorporationSole ProprietorshipPartnershipLimited Liability Corporation

Date Opened / Date IncorporatedFiscal Year EndFederal ID #

Names of Officers, Partners, or Owners

*Name / Title*Years Involved in Business*Home Address, City, State, Zip(optional)(optional)

*Home Phone*Percentage of OwnershipPrevious Address (if less than one year)*Spouse Name

Additional Officer, Partner, or Owner

* Name / Title* Years Involved in BusinessHome Address, City, State, Zip(optional)(optional)

* Home Phone* Percentage of OwnershipPrevious Address (if less than one year)Spouse Name

Previous Application

* Has anyone involved in the business ever applied with us before?YesNo

* Are there any past or existing judgments, liens, lawsuits, repossessions or bankruptcy filings against or by the business or any of its owners or partners?YesNo

Existing Trade References

* Name / Business Name:* PhoneUse For

* Address, City, State, ZipCredit Line $

* Name / Business Name:* PhoneUse For

* Address, City, State, ZipCredit Line $

Bank References for Business and Officers, Partners, or Owners

* Name / Title (Business, Officer, Partner, Owner)* PhoneSavings Acct. #

* Address, City, State, ZipCredit Line $* Checking Acct #

Name / Title (Business, Officer, Partner, Owner)PhoneSavings Acct. #

Address, City, State, ZipCredit Line $Checking Acct #

NOTICE:

The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the bases 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 this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington D.C. 20580

BUSINESS RELEASE:

Applicant Name (To Be Used as Digital Signature)Date

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ADAMS GRANITE COMPANY, INC.

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