LANDING BIOTECH INC CREDIT APPLICATION FORM fax: 617-964-1187 email: sales@landingbiotech.com Date________________ Account No._______________ Company Name___________________________________Tel No._______________ Address______________________________________________________________ City________________________________State__________Zip_______________ Mailing Address______________________________________________________ Date Business Started____________Division____________________________ Federal ID No._________________________Fax No._______________________ Corporation___Partnership___Sole Proprietorship___Other______________ Names of Officers & Principles Title _______________________________ _____________________________________ _______________________________ _____________________________________ Trade/Vendor Credit References: Name______________________________________Account No.________________ Address______________________________________________________________ City________________________________State___________Zip______________ Contact_________________________________________Tel No.______________ Name______________________________________Account No.________________ Address______________________________________________________________ City________________________________State___________Zip______________ Contact_________________________________________Tel No.______________ Bank Reference: Bank Name____________________________________Checking_____Saving_____ Address______________________________________________________________ City________________________________State___________Zip______________ Contact_________________________________________Tel No.______________ Account Name________________________________Account No.______________ Order Information: Purchusing Contact Name_________________________Tel No.______________ Email___________________________________________Fax No.______________ Purchase Order Numbers are required__________________________________ Partial Shipments are acceptable ____________________________________ (Payment will be processed.) Accounts Payable Contact Name________________________________________ Tel No.______________________Office Hours____________________________ Payment Issued by Payer's Name_______________________________________ Authorization is hereby granted to Landing Biotech Inc. for release of all pertinent banking information needed to astablish account credit. Print Name of Applicant______________________________________________ Signature of Applicant_______________________________________________ Title__________________________________________Date__________________ Payment of account is due within net 30 days of invoice date. Any accounts unpaid at 60 days are subject to a service charge of 1 1/2% per month, 18% annually. Shipment delays will occur when accounts are past 60 days.