COMPANY NAME

STREET ADDRESS

CITY

STATE

ZIP

MAILING ADDRESS

CITY

STATE

ZIP

PHONE #

FAX#

TYPE OF BUSINESS           — Sole Prop     — Partnership     — Subsidiary     — LLC     — Corporation     — Other_________________

SUBSIDIARY OF (if subsidiary)

Years In Business

Years At Present Address

Contractor License No.

Year Issued

PROPRIETORS, PARTNERS OR OFFICERS

NAME

TITLE

  HOME ADDRESS

PHONE#

NAME

TITLE

  HOME ADDRESS

PHONE#

NAME

TITLE

  HOME ADDRESS

PHONE#

TRADE REFERENCES

(List 4 businesses that extend credit on an open account)

COMPANY

PHONE#

  ADDRESS

FAX#

COMPANY

PHONE#

  ADDRESS

FAX#

COMPANY

PHONE#

  ADDRESS

FAX#

COMPANY

PHONE#

  ADDRESS

FAX#

CREDIT LINE AMOUNT REQUESTED:  $

  I UNDERSTAND AND AGREE THAT IF The Glass Block Place, Inc. EXTENDS CREDIT TO ME AND/OR MY COMPANY, I WILL PAY OR CAUSE TO BE PAID ALL INVOICES WITHIN 30 DAYS.  SHIPMENT OF ALL GOODS WILL BE AT OUR EXPENSE, F.O.B. PRODUCING PLANT.  ALL ORDERS ARE SUBJECT TO ACCEPTANCE AND APPROVAL BY The Glass Block Place, Inc. FOR ANY AMOUNTS NOT PAID WITHIN 30 DAYS FOLLOWING THE DATE OF INVOICING, I AGREE TO PAY OR CAUSE TO BE PAID A SERVICE CHARGE OF 1% PER MONTH, (18% ANNUM), PLUS ANY SUCH ATTORNEY FEES, LEGAL AND COURT COSTS AS MAY BE NECESSARY TO ENFORCE COLLECTION.

AUTHORIZED

SIGNATURE     X                                                             TITLE                                                  DATE

BANK REFERENCES

I HEREBY AUTHORIZE THE BANK TO RELEASE TO  The Glass Block Place, Inc. ALL INFORMATIONREQUESTED.  IT IS UNDERSTOOD THAT ALL INFORMATION WILL BE KEPT CONFIDENTIAL BY The Glass Block Place, Inc.

Authorized Signature X______________________________________________Title________________________Date____________________

BANK NAME________________________________________________________________________________________________

ADDRESS___________________________________________________________CITY/STATE/ZIP_________________________

CONTACT___________________________________TELEPHONE____________________________FAX____________________

ACCOUNT NUMBER(S)______________________________________________________________________

PERSONAL GUARANTY

IN CONSIDERATION OF CREDIT HERETOFORE OR HEREAFTER GRANTED BY The Glass Block Place, Inc. (“CREDITOR”)

TO APPLICANT (“DEBTOR”), THE UNDERSIGNED HEREBY UNCONDITIONALLY GUARANTEES TO CREDITOR FULL PAYMENT WHEN DUE OF ANY INDEBTEDNESS OF DEBTOR FOR (1) GOODS HERETOFORE OR HEREAFTER SOLD OR CONSIGNED TO, OR WORK-IN-PROGRESS IDENTIFIED FOR, DEBTOR BY CREDITOR OR (2) SERVICES HERETOFORE OR HEREINAFTER PERFORMED FOR DEBTOR BY CREDITOR, TOGETHOR WITH LAWFUL INTEREST FROM DATE DUE AND ALL EXPENSES OF COLLECTION, INCLUDING COURT COST AND REASONABLE ATTORNEY’S FEES.

THIS GUARANTY SHALL BE DIRECTLY ENFORCEABLE AGAINST THE UNDERSIGNED WITHOUT FIRST RESORTING TO ANY REMEDIES AGAINST DEBTOR. THIS GUARANTY SHALL BE A CONTINUING GUARANTY AND SHALL REMAIN IN FULL FORCE AND IN EFFECT UNTIL UNDERSIGNED GIVES WRITTEN NOTICE, BY CERTIFIED OR REGISTERED MAIL, TO CREDITOR TO EXTEND NO FURTHER CREDIT ON THE SECURITY OF THIS GUARANTY.   SUCH NOTICE SHALL BE INEFFECTIVE AS TO ANY OBLIGATION (BILLED OR UNBILLED) EXISTING AT THE TIME SUCH NOTICE IS RECEIVED BY CREDITOR.  THE UNDERSIGNED HEREBY ASSENTS TO ALL TERMS AND CONDITIONS MADE OR TO BE MADE WITH CREDITOR BY DEBTOR.  ANY INDULGENCES, RENEWALS OR EXTENSIONS OF ANY INDEBTEDNESS GUARANTEED HEREBY SHALL NOT RELEASE THE UNDERSIGNED AS A GUARANTOR HEREUNDER.

REFERENCES TO UNDERSIGNED INCLUDE EACH AND ALL OF THE UNDERSIGNED AND THEY SHALL BE JOINTLY AND SEVERALLY LIABLE HEREUNDER.  THIS GUARANTY SHALL BE FOR THE BENEFIT OF THE CREDITOR, IT’S SUCCESSORS AND ASSIGNS AND SHALL BE BINDING UPON THE UNDERSIGNED AND THEIR ASSIGNS, HEIRS, EXECUTORS AND OTHER LEGAL REPRESENTATIVES

INTENDING TO BE LEGALLY BOUND HEREBY, THE UNDERSIGNED HAVE EXECUTED THIS GUARANTY THIS DAY OF _________________________, _____________.

NAME_______________________________________________      NAME___________________________________________________

TITLE_______________________________________________       TITLE___________________________________________________

AUTHORIZED                                                                                       AUTHORIZED

SIGNATURE                                                                                           SIGNATURE

X__________________________________          X_____________________________________

THE UNDERSIGNED HEREBY APPLIES TO The Glass Block Place, Inc. FOR CREDIT.   IT IS UNDERSTOOD AND AGREED THAT THE UNDERSIGNED SPECIFICALLY CONSENTS TO The Glass Block Place, Inc. INVESTIGATING THE APPLICANT’S CREDIT HISTORY FOR THE PURPOSES OF EXTENDING CREDIT.

IF CREDIT IS EXTENDED, I UNDERSTAND THAT The Glass Block Place, Inc. CREDIT TERMS ARE NET 30 DAYS.  The Glass Block Place, Inc. SHALL HAVE THE RIGHT TO CHARGE, IF PAYMENTS ARE NOT MADE PURSUANT TO THE TERMS OF The Glass Block Place, Inc. A LATE CHARGE OF 1% PER MONTH OR THE HIGHEST RATE PROVIDED BY THE LAW IN THE STATE OF WEST VIRGINIA.  SHOULD SUIT BE INSTITUTED TO COLLECT ANY DEBTS OF THE UNDERSIGNED, THE UNDERSIGNED AGREEES TO PAY ALL ACTUAL COSTS OF COLLECTION AND ATTORNEY’S FEES.

DATE____________________________ SIGNATURE X_____________________________________________________

IN CONSIDERATION OF CREDIT GRANTED BY The Glass Block Place, Inc. THE UNDERSIGNED PERSONALLY GUARANTEES ANY AND ALL CHARGES AND/OR MONEY DUE The Glass Block Place, Inc. THE UNDERSIGNED AGREES TO MAKE PAYMENT WITHIN 30 DAYS.

DATE____________________________ SIGNATURE X______________________________________________________