Newark Asphalt

The following information is submitted as a basis for the extension of credit. (* indicates a required field.)
*	Individual or Company Name:
*	Physical Address:
*	Mailing Address:
*	City:		*	State:	* Zip Code:
*	Phone:			Fax:
*	Email:
*	Type of Business:		*	Federal ID:
*	Year Established:		*	State:
*	We are at this location since: (year)
*	Type of ownership:	Corporation Partnership Limited Partnership Individual

Principal owners or stockholders and officers are:
1.	*	Name:	*	Title:	*	Address:
	*	City:	*	State:	*	Zip Code:

2.		Name:		Title:		Address:
		City:		State:		Zip Code:

*	Principal's home phone number:	*	Principal Name:
*	Cell:		Fax:
*	Email:

Financial Information:
*	Name of Bank:
*	Address:
*	Acct.#:
*	Contact:
*	Phone:	Fax:

Trade References: (Please Type)
*	Name:	*	Address:	*	Phone:	Fax:
	Name:		Address:		Phone:	Fax:
	Name:		Address:		Phone:	Fax:

Newark Asphalt Corp. may verify the above reference and any other information to determine credit capacity.
Our current terms: Net 30 days, finance charge of 1-1/2 precent per month (18% per annum) will be applied to the net amount outstanding as of the 30th of each succeeding month after 60 days.

Newark Asphalt Corp. is hereby authorized to extend credit to the above named firm and the undersigned guarantee payment, individually and collectively. In the event of any default as a result of which Newark Asphalt Corp. must retain counsel or bonded collection agency, costs will be added to the bank due.

(Please Type and Sign)
Name ____________________________________ Signature ______________________________________ Date ____________________

Approved by ________________________________________ Date _________________________ Credit Limit ______________________

NEWARK ASPHALT CORP.
FOOT OF PASSAIC STREET
NEWARK, NEW JERSEY 07104
973-482-3503

Bank Release Form

Please fill and sign the statement below, which will be sent or faxed to your bank. Your permission is required to
access account information. This will expedite the processing of your credit application.

I,_______________________________________ give ______________________________________________

(Company Official) (Bank Name)

permission to release account information to Newark Asphalt Corp. for the purpose of obtaining credit.

Thank You.

_______________________________________________________
Signature and Date

_______________________________________________________
Title

_______________________________________________________
Account Number

*Company Officer name
*Bank Name