Dealer Application

Date:__________ DEALER APPLICATION For the purpose of obtaining merchandise from Western International Inc., the following statement made in writing is warranted to be true, intending that you should reply on same as correct: Applicant hereby authorizes Western International Inc., or its agents, to investigate the references listed to ascertain the undersigned’s personal, partnership or corporate and financial responsibility. Select Type of Payment Account: _____C.O.D. _____Open Account _____Credit Card Company Name:______________________________________________________________________________ Office Telephone:____________________ Fax:___________________ Email:____________________________ Store Hours:____________________________________Website:_______________________________________ Billing Address:_____________________________ Shipping Address:__________________________________ City_________________State______Zip_____ City______________________State______Zip_____ Select Type of Ownership: ________Corporation ________Partnership ______Proprietorship Full Legal Names of Owners:_____________________________________________________________________ _____________________________________________________________________________________________ Owners' Home Address:______________________________________City______________State______Zip______ Phone Number:_______________ Owners' Home Address:______________________________________City______________State______Zip______ Phone Number:_______________ Owners' Home Address:______________________________________City______________State______Zip______ Phone Number:_______________ Type of Business:_____________________________________________ Start-up Date:______________________ Current Owners Since:____________________________ Special Interests:_______________________________ Other business interests of owners:_________________________________________________________________ Firm Names and Addresses:_______________________________________________________________________ ______________________________________________________________________________________________ RESALE TAX NUMBER:_________________________________ (provide copy of permit) Authorized buyers:_______________________________________________________________________________ Credit Amount Desired: $_______________ Authorized Signature:______________________________ Authorized Signature:_____________________________ Type or Print Type or Print Signature:_______________________________________ Signature:______________________________________ Western International Inc. 2220 Delaware St. Lawrence, KS 66046 office 785-856-1840 fax 785-856-1845 www.yourbooksource.com List other publishers that supply your company: Major Suppliers Address City/State Zip 1. _______________________________________________________________________________________________________ 2. _______________________________________________________________________________________________________ 3. _______________________________________________________________________________________________________ 4. _______________________________________________________________________________________________________ 5. _______________________________________________________________________________________________________ Bank References: Bank Name:________________________________ Branch Address:__________________________________________________ Account Number: Checking_________________________ Savings____________________ Credit Line $_____________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ AGREEMENT I/We agree to pay for all the charges to our account under the following terms and conditions: All sums are due and payable at the mailing address of Western International Inc. 2220 Delaware St. Lawrence, Kansas 66046. I/We represent, as the applicant herein, that all debtors are currently being paid in the normal course of business, as they become due, and no insolvency exists as defined in the Bankruptcy Reform Act of 1980, and that all orders will cease should the condition as to insolvency become incorrect. In the event of default of any payment that may become due, I/we agree to pay interest at the rate of 2% per month on the principle balance owing from the date of such default. In the event suit is filed by Western International Inc. to enforce payment of all sums due under this agreement, I/we agree to pay reasonable court costs and attorney fees. Statement of authorization and acknowledgements: I hereby certify that I am authorized to disclose information on behalf of the applicant and that all of information provided is true and correct. I authorize third parities to release credit information to Western International Inc. I also acknowledge and agree to adhere to Western International Inc. credit terms of net 30 days from date of invoice and understand the interest will be charged at a rate of 2.0% per month (24% per year) on all past due balances. Signature______________________________________________Title_________________________________Date_____________________ ____________________________________________________________________________________________________________________ PERSONAL GUARANTEE FOR CORPORATE DEBT In consideration for which credit may be granted by Western International Inc. to the above applicant corporation, I/we undersigned agree to further and wholly guarantee any debt incurred by __________________________________or it's agent, and I/we agree to the terms listed in the above agreement. This personal guarantee for corporate debt may be revoked by the undersigned upon thirty days written notice to Western International Inc. of undersigned's intention to revoke said personal guarantee. The undersigned shall remain liable for any charges incurred with Western International Inc. prior to the end of said thirty day period. ALL CORPORATE OFFICERS MUST SIGN Guarantor___________________________________________________________________________________________Date__________________________ Guarantor___________________________________________________________________________________________ Date__________________________ Guarantor___________________________________________________________________________________________Date__________________________ Name of person to contact regarding ACCOUNTS PAYABLE and phone number: ______________________________________________________________ Thank you! Western International Inc. 2220 Delaware St. Lawrence, KS 66046 office 785-856-1840 fax 785-856-1845 www.yourbooksource.com