Park Hill Store

Park Hill Collections, LLC
1400 East 28th Street
Little Rock, AR 72206

Ph: 501.603.0600
1.888.603.3334
Fax: 501.603.0960
sales@parkhillcollection.com

Date:	8/20/2008
Business Name: *
Phone Number: *
Fax Number: *
Email Address: *
Parent Company Legal Name: *
DBA Name:
Business Address: *
Business City: *
Business State: *
Business Zip Code: *
Type of Business: *
Length of Time in Business (in years): *
Legal Structure of Business: *	Proprietorship Partnership Corporation
Is Business Tax Exempt? *	Yes No If Yes, attach a copy of certificate.
D & B Number: *
Federal ID Number: * (SSN if individual)

IF CORPORATION, LIST NAMES OF OFFICERS AND TITLES, ALL OTHER ENTITIES LIST NAME(S)
AND ADDRESS(ES) OF OWNER(S) OR PARTNER(S).

NAME	ADDRESS (TITLE, IF CORPORATION)	CITY/STATE/ZIP

THE FOLLOWING ARE TRADE REFERENCES WE ARE PRESENTLY DOING BUSINESS WITH

Company Name:	1.	2.	3.
Street Address:	1.	2.	3.
City, State, Zip:	1.	2.	3.
Phone Number:	1.	2.	3.
Account Number:	1.	2.	3.

Bank Contact:			Bank Name:
Phone Number:			Account Number:
Address:			City:
State:			Zip Code:

This information has been submitted for consideration of extension of credit by Park Hill Collection. I authorize the above-name firms and financial institutions to furnish any information concerning our account to the requestor. I agree to hold these firms and/or the employees harmless for providing the requested information. Authorization is provided to pull a credit report. I also agree to furnish additional information as may be required from time to time, and I authorize you to perform additional investigation and inquiries deemed necessary to establish/maintain/increase our account/credit line.

I have received a copy of the "Conditions of Sale and Terms of Payment" which is a part of this application and I am duly authorized to sign on behalf of the applicant to the terms of this agreement and establish credit for the applicant. Condition of Sale and Terms of Payment can not be amended unless approved in writing by Park Hill Collection's President.

SIGNATURES OF TWO (2) OWNERS / CORPORATE OFFICERS ARE REQUIRED (IF APPLICABLE)

You will receive an email with a signature file. Please fill out, sign and fax back to us at 501.603.0960.

* required fields

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