Application For Credit

American Safety Tread Co., Inc. Pelham, Alabama Phone: (800) 245-4881  Fax: (205) 663-9610

To help us establish an account in your company name and to expedite processing of your initial orders, fill in the following statement completely and return as quickly as possible. Your signature will aid in obtaining the requested reference information.

Date Firm Name______________________________________________________________ Phone Number______________________Fax Number__________________________

Billing Address                                                  Shipping Address

Firm:_______________________________

Firm:_______________________________

Address:___________________________

Address:___________________________

City:_______________________________

City:_______________________________

State:_____________

State:_____________

Zip:_____________

Zip:_____________

Phone:____________

Fax:____________

Phone:____________

Fax:____________

A/P Manager:________________________

Year Established ______________ Officers________________________________Pres. At present location since________               ________________________________V.P.

REFERENCES (Only use names of firms you buy from on open account)

Firm:_______________________________City, State____________________________

Tel:__________________________Fax:____________________Act#_______________

Firm:_______________________________Ciy, State____________________________

Tel:__________________________Fax:____________________Act#_______________

Firm:_______________________________City, State____________________________

Tel:__________________________Fax:____________________Act#_______________

We certify that all the information on this form is correct. We fully understand your CREDIT TERMS ARE NET 30 DAYS and agree to the proper payment in consideration of extended credit. Signed _____________________________Date________________________________ Title________________________________