Robvon Backing Ring Co.  Internet Fax Credit Application

Company Name: _________________________________________________________________

Division/Subsidiary of:________________________________________________________

Bill-To Address:_______________________________________________________________

Phone: _______________  Fax: _______________  Contact: ________________________

Ship-To Address: _______________________________________________________________

Phone: _______________  Fax: _______________  Contact: ________________________

Authorized Purchasing Agents: _________________________________________________

Do you use Purchase Order Numbers:  YES  NO

Corporation  Partnership/Sole-Proprietor  Nonprofit  ID Number: _______________

Re-Sale  End User  Tax Exempt Number: _______________________  State: _________

Trade References:

Company:_______________________________________________________________________

Address:_______________________________________________________________________

Phone: __________________ Fax: __________________ Contact: ____________________


Company:_______________________________________________________________________

Address:_______________________________________________________________________

Phone: __________________ Fax: __________________ Contact: ____________________


Company:_______________________________________________________________________

Address:_______________________________________________________________________

Phone: __________________ Fax: __________________ Contact: ____________________

Bank Reference:

Bank Name: ____________________________________________________________________

Address: ______________________________________________________________________

Account Number: _________________________

Phone: __________________ Fax: __________________ Contact: ____________________

Please Note:  All orders will be shipped C.O.D. until receipt and approval of
              the above information is obtained, and you account is approved.
			  
			   Thank you for your cooperation.