Please print this form, complete and submit to AMP-Cherokee.

Company: _________________________________________________________

Address: __________________________________________________________

City: _____________________________________ State:_____ Zip:__________

Contact: __________________________________________________________

Title: _____________________________________________________________

Phone: __________________________ Fax:_____________________________

OWNERSHIP: ___ Sole Owner ___ Partnership ___ Corporation

PRINCIPAL:

Name: ___________________________________________________________

Title: ____________________________________________________________

SS#: ____________________________________________________________

Home Address: ____________________________________________________

PRINCIPAL:

Name: ___________________________________________________________

Title: ____________________________________________________________

SS#: ____________________________________________________________

Home Address: ____________________________________________________

PRINCIPAL:

Name: ___________________________________________________________

Title: ____________________________________________________________

SS#: ____________________________________________________________

Home Address: ____________________________________________________

BANK REFERENCE ___ Checking ___ Loan ___ Savings

Name: ___________________________________________________________

Account #: ________________________________________________________

Address: _________________________________________________________
(City) (State) (Zip)

BANK REFERENCE ___ Checking ___ Loan ___ Savings

Name: ___________________________________________________________

Account #: ________________________________________________________

Address: _________________________________________________________
(City) (State) (Zip)

TRADE REFERENCES

Name _____________________________________________________________


Address ___________________________________________________________


Phone / Fax ___________________________ / ___________________________

Name _____________________________________________________________


Address ___________________________________________________________


Phone / Fax ___________________________ / ___________________________


Name _____________________________________________________________


Address ___________________________________________________________


Phone / Fax ___________________________ / ___________________________

Note: By completing this credit approval application, the above corporation, partnership or sole proprietorship hereby authorizes Cherokee Instruments, Inc. to contact our trade and bank references for the normal credit information, as may be required.

You must also submit the Credit Approval Application and the Personal Guarantee.

AMP-Cherokee
901 Bridge Street
Fuquay-Varina, NC 27526
919/552-0554 tel
800/399-4CEM (4236)
919/552-3991 fax
info@ampcherokee.com