The following information is provided for the purpose of applying for credit in accordance with the terms and conditions of DIRECT PRODUCE, INC. All the fields below are required for us to process your application.

Business Name: Tel #: Fax #: Street: City: State: Zip: PACA LIC. #: FED I.D #: BLUE BOOK #:
Type of Business:
Individual (name of owners): 1. 2. Partnership (name of partners): 1. 2. Corporation (name of officers): 1. 2.
If Incorporated:
Year Incorporated: State Incorporated: State I.D. #:
Accounts Payable Clerk: Accountant: Controller:
INFORMATION OF OWNER, PARTNERS OR CORPORATION’S OFFICERS: (RESIDENT ADDRESS AND TELEPHONE)
Name: Street: City: State: Zip:	Telephone #: Social Sec. #: CA Driving License:
TRADE REFERENCES: (PLEASE LIST NAMES OF OPEN ACCOUNTS WITH PRODUCE COMPANIES ONLY)
Name: Street: City: State: Zip:	Telephone #: Account # : Contact:
Name: Street: City: State: Zip:	Telephone #: Account # : Contact:
Name: Street: City: State: Zip:	Telephone #: Account # Contact:
BANK REFERENCE:
Name: Street: City: State: Zip:	Telephone #: Account #: Contact:
The above trade and bank references are hereby authorized to release information to DIRECT PRODUCE, INC. upon request. The undersigned hereby agrees to personally guarantee payment of indebtness and to enforce this personal guarantee, then the undersigned further agrees to pay any interest, legal and other collection fees.
Name: Title: Date: