AmeriSci Group 13635 Genito Road Richmond, VA 23112 Tel: (804)763-1200 Fax: (804)763-1800 Online Credit Application Form

Part I ($500 Line of Credit Pre-Approved : Complete Part I)

Legal Business Name: Doing Business As (DBA): Tax ID: Accounts Payable Contact: Billing Address: City, State, Zip , , Phone #: Fax #: E-mail Address: I/We, the applicant (business named above), authorize the AmeriSci Group to obtain credit reports and contact references as deemed necessary for the purposes of extending credit and to obtain updated credit reports at AmeriSci Group's discretion in the maintenance of any credit extended. Owners, shareholders, partners and/or corporate officers of the applicant authorize AmeriSci Group to investigate the credit record of named principals in determination of a credit decision. I/We agree in using the credit extended for the purchase of goods and/or services from any AmeriSci location including AmeriSci Boston, AmeriSci New York, AmeriSci Los Angeles, AmeriSci Richmond, And AmeriSci Bio-Chem, that all invoices are due and payable in full within thirty (30) days of the invoice date. Late charges, not in excess of those permitted by law, will be added to overdue invoices. I/We agree to be responsible for all attorneys' fees and/or collection costs in the event that the applicant's account is placed with a professional for collection or if suit is filed for collection. ________________________________________ Authorized Signature Title Printed Name Date

Part II (Additional Credit : Complete Parts I & II)

Amount of Credit Line Requested: $ Type of Business: Public Corporation  Private Corporation  Partnership Sole Proprietorship  LLC Date Formed:      Annual Sales Volume:   $ Years under Current Ownership:              Nature of business services:    This company is: Headquarter  Division  Branch  Subsidiary  Other: Name of Bank: Phone #: Bank Officer: Account #: Business References Name: Phone: Name: Phone: Name: Phone:

Please Print and Fax this Credit Application to (804)763-1800