Please fill out the form below and someone will follow up with you shortly. Business Telephone (required) Business Fax Legal Entity Name (required) Email Address (required) Store Name Store Address City State Zip Code Owners Name Date of Birth Home Address Home City Home State Home Zip Code Home Phone Drivers License Number Owners SSN Business Type Sole ProprietorshipPartnershipCorporationLLCOther Federal Id Number Tobacco Tax Number Sales Tax Number Length of time under your ownership Estimated Weekly Purchases Credit Reference One Reference Name Contact Person Address City State Zip Telephone Account Number Credit Reference Two Name Contact Person Address City State Zip Code Telephone Account Number I, the undersigned do hereby authorize my bank and trade references to release any information that is necessary to Andalusia Distributing Co., Inc., to establish an open account with ADC. By entering my name below I understand that it constitutes as a legal binding signature. Signature Date FOR VALUE RECEIVED, WE the undersigned owners, partners, or holders of the majority of the stock of the above named Business, do hereby personally guarantee the indebtedness of the said Business to Andalusia Distributing Co., Inc., now due, or hereafter contracted for, including interest and attorney’s fees, even if payment of indebtedness is from time to time extended or renewed. ADC, Business, and the undersigned agree that Alabama Law shall govern the construction of this Agreement and that the Courts of the 22nd Judicial Circuit in Covington County shall properly have jurisdiction of any disputes regarding this Agreement. Signature Date Witnessed By Signature Date Witnessed By Signature Date Witness This is to certify that all goods purchased from ADC are for resale. It is further agreed that all goods purchased from ADC remain the property of ADC until fully paid by Business and shall not be subject to collateral for other loans. The above information submitted is true and correct to the best of my knowledge. Signature Date Δ
