Please print this form, provide all information requested, and return by fax or regular mail.
Fax to: 423-775-0611. Mail to: Interactive Products Corporation, 148 Bluff Road, Dayton, TN 37321.

IMPORTANT!
You must provide contact names and fax numbers for your references.
Any application received without contact names and fax numbers will not be processed.
You must also complete the BANK REFERENCE.

COMPANY PROFILE Company Name: _________________________________________________________ Doing Business As: _________________________________________________________ Address: _________________________________________________________   _________________________________________________________   _________________________________________________________ City: _________________________________________________________ State: ________________________ Postal Code: ___________________ Country: ________________________ Contact: ________________________ Phone: ___________________ E-mail: ________________________ Website: ___________________ Year Established: ________________________     Business Type: ________________________     # of Branches: ________________________     # of Salespeople: ________________________     OWNER INFORMATION Name: _________________________________________________________ Home Address: _________________________________________________________   _________________________________________________________ City: _________________________________________________________ State: ________________________ Postal Code: ___________________ Country: ________________________ Social Security No: ________________________ Home Phone: ___________________ Credit Requested: $____________     Products of interest: _________________________________________________________ CREDIT REFERENCES Reference 1: _________________________________________________________ Address: _________________________________________________________   _________________________________________________________ Contact: ________________________ Phone: ___________________ Credit Limit: ________________________ Fax: ___________________ Reference 2: _________________________________________________________ Address: _________________________________________________________   _________________________________________________________ Contact: ________________________ Phone: ___________________ Credit Limit: ________________________ Fax: ___________________ Reference 3: _________________________________________________________ Address: _________________________________________________________   _________________________________________________________ Contact: ________________________ Phone: ___________________ Credit Limit: ________________________ Fax: ___________________ Accts. Payable Contact: ________________________ Phone: ___________________ PROPRIETOR GUARANTEE By signing this Application, I acknowledge that I have personally guaranteed the debts and obligations of my business and agree that I am personally obligated to perform all of the terms of, and make all payments to Interactive Products Corp. required by the agreement of which this Application is a part. I also authorize the listed credit references to release any information regarding my credit history. Authorized Signature: ________________________ Date: ___________________ How did you find us? _________________________________________________