Legal Business Name: _______________________________________________

DBA: _______________________________________________

Address: _______________________________________________

_______________________________________________

Phone: _____________________ Fax: _____________________

Year established: ________ Type of Business: _____________________

Company Owners____________________________________________/

Officers’ Names______________________________________________

Title________________________________________________________

City of Residence______________________________________________

Phone #_____________________________________________________

Bank Reference (name/branch): ____________________________________________

Phone #: _______________________ Account #: _______________________

Address: ____________________________________________________________

Trade References (list 3 from whom purchases are made on a credit basis)

Name Address Telephone Fax#

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

TERMS AND CONDITIONS OF SALE

1. All orders are subject to acceptance by Atlantic Pottery.

2. Terms are NET 30 days, from invoice date.

3. The purchaser agrees to pay, in the event this account becomes delinquent and is turned over to a collection agency or attorney for collection, the collection fees and/or attorney fees , plus court costs, and/or any other miscellaneous expenses incurred as a result of the purchaser’s failure to pay. A 1.5% interest rate per month (18% per annum) will be charged and payable on all overdue accounts.

The undersigned, having read and accepted the terms and conditions of sale hereby authorize Atlantic Pottery to contact the above listed references to obtain credit information.

____________________________ ___________________________ ____________

Print Name Signature Date

______________________ ____________________ _______________

****Upon completion of the form, please fax back to Atlantic Pottery at 954-727-0009. Thank you.