Credit Application

                               Form to Establish a Credit Account at Southwest Science

Please Fax this form or equivalent information with signature to Southwest Science at 609-499-5754
or Email it to info@southwestscience.com

This form may accompany an order or it can be sent in advance of an order. Upon verifying the
information you will receive notice of your credit limit.

Thank you.

Business name: ________________________________________________________________
Business Phone Number: ________________________     Business FAX number_____________
Accounts Payable Contact:_______________________     Phone Number __________________
Email address:__________________________________________________________________

Company Invoice Mailing Address:                Company shipping Address if different:
_______________________________        __________________________________
_______________________________        __________________________________
_______________________________        __________________________________


1. Bank Reference:
Bank Name:__________________________     Address: _______________________________
Phone:______________________________     FAX:___________________________________
Account # ___________________________     Contact:________________________________

2. Trade Reference 1
Business Name: ________________________ Address:_______________________________
Phone:________________________________ FAX:__________________________________
Contact:_______________________________ Typical account balance:__________________

3. Trade Reference 2
Business Name: ________________________ Address:_______________________________
Phone:________________________________ FAX:__________________________________
Contact:_______________________________ Typical account balance:_________________

Credit Terms:   Southwest Science's credit terms are net 30 days from invoice date. We charge 1% interest
per month compounded on overdue accounts plus collection costs.

Signature authorizing Southwest to contact references and agreement with Southwest standard credit terms:

________________________________________ Date: _____________