1045 W. 47th St., Chicago, IL 60609

773-523-1907 or fax us @ 773-523-9217

Summit Division: 5707 Archer Rd., Summit, IL 60501

708-594-9292 or fax us @ 708-594-1477

PLEASE PRINT AND FAX BACK TO WRC @ 773-523-9217

Firm Name:__________________________________________________________

Phone:______________________Fax:______________________e-mail_______________

Address:___________________________________________________________________

City:____________________________State:_______________Zip:___________________

Principal Officers or Owners:

Name:________________________________Title:_________________________________

Name:________________________________Title:_________________________________

Years in Business:________________________Current Location:___________________

Accounts Payable Manager:__________________________Phone:___________________

Type of Business:___________________________________________________________

Sole Prop:___________Partnership:_____________Corp:__________

References:

Bank:______________________________________ Account#:_____________________

Bank Officer:________________________________Phone:________________________

SUPPLIERS:

Supplier:____________________________________Phone:________________________

Address:___________________________________________________________________

Supplier:____________________________________Phone:_________________________

Address:___________________________________________________________________

Supplier:___________________________________Phone:_________________________

__________________________________________________________________________

Do You Require Purchase Orders?___________________Verbal?___________________

Please list all authorized personnel and their positions:

__________________________________________________________________________

__________________________________________________________________________

I certify that all the above information is valid and correct. I also understand that invoices are to be paid in 30 days. I hereby authorize the release of any and all credit information requested by Wirtz Rentals Co.

Signed:____________________________________Title:____________Date:___________

(office use only)

Checked by:____________________Approved by:_________________Date:___________

Account #___________________Card:______