| Financial Statement: |
 A copy of
my most recent financial statement attached |
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Ship to Information:
Please fill out if you have additional "Ship To"locations
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Send Bill To:
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Check if residential address
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Main Address
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Ship to Address
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1.
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| Address________________________________ |
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| City_____________ |
State______ |
Zip________ |
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2.
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| Address________________________________ |
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| City_____________ |
State______ |
Zip________ |
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3.
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| Address________________________________ |
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| City_____________ |
State______ |
Zip________ |
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4.
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| Address________________________________ |
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| City_____________ |
State______ |
Zip________ |
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5.
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| Address________________________________ |
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| City_____________ |
State______ |
Zip________ |
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6.
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| Address________________________________ |
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| City_____________ |
State______ |
Zip________ |
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| Purchasing Info: |
You must
get a PO Number from us. |
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Any restrictions
on who can place an order? If so, please explain. |
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| ___________________________________________________________________________ |
| ___________________________________________________________________________ |
| Personal Guarantee |
I _____________________, residing at _________________________,
for, and in consideration of your extending credit at my request to (company
name)__________________________ (Hereinafter refered to as the "Comapny",
of which I am (title) _______________________
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I hereby personally guarantee to you the payment at OPTIMUSM
INC., in the state of TENNESSEE of any obligation of the Company and agree
to pay on demand any sum which may become due to you be the Company whenever
the Company fails to pay the same. It is understood that this guarantee
shall be continuing and irrovocable guarantee and imedemnity for such indebtedness
of the Company. I waive notice of default, non payment and consent to any
modification of renewal of the credit agreement guaranteed.
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| Signature of Guarantor______________________________________ Date
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| Resident Address_____________________ City______________ State_____
Zip________ |
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