Company Name

Tel#

Address

Fax#

City

Cell

State

Email

Zip

Website

Shipping Information

same

(if not, please fill in below)

Shipping Address

Zip

City

Tel

State

Fax

JBT Listed/Rated

D&B Listed/Rated

JBT ID#

Source

Company Type

Individual     Partnership    

Corporation

How long have you been under this company?(in years)

Do you currently operate under any other names? (Y/N)

Have you previously operated under any other names?

Key Employees

Diamond Buyer

Bookkeeper

Manager

Asst.Manager

Name of Owner

Driver's License #

Home Address

Social Security #

Home Tel#

Birth Date

Trade References (New York Diamond Dealers)
Please supply at least three Active Diamond or Jewelry Trade references.

Name

JBT Listed

Address

Contact

City,State,Zip

Fax#

Phone

Acct #

Name

JBT Listed

Address

Contact

City,State,Zip

Fax#

Phone

Acct #

Name

JBT Listed

Address

Contact

City,State,Zip

Fax#

Phone

Acct #

Bank References

Name

Acct Name

Address

Acct#

City,State,Zip

Tel#

Contact

Fax#

I authorize the above named Bank to release information regarding my business accounts.

Signature

Dated

The undersigned expressly agrees that if the above account becomes delinquent and forced to be placed in the hands of an attorney, an attorney's fee of 25% will be due in addition to the principal sum and a delinquent finance charge of 1.5% per month of 19% per annum. The undersigned who desires to do business with Perrier Gems International, Inc. agrees that if a lawsuit is necessary to collect money owing Perrier Gems International, Inc, that the venue of the lawsuit will be in the state of New York and that the state of New York will have jurisdiction over the subject matter and also over the parties to the lawsuit. Before a lawsuit is filed, Perrier Gems International, Inc, through its attorney, agrees to notify the debtor by certified mail, return receipt requested. The undersigned expressly agrees that the above method of certified mail, return receipt requested, will be sufficient notice to effectuate service over the defendant, and the defendant also agrees to wave citation. It is expressly understood by all parties that this agreement is to facilitate the legal process only in the event a lawsuit is necessary to satisfy any obligation to Perrier Gems International, Inc. Premission is hereby granted for Perrier Gems International, Inc. to obtain company credit reports in connection with these proposed accounts.

Signed by:

Print:

Date:

Sales tax permit #:

Credit application will not be processed unless completed in full, signed and dated.

I, (name) guarantee the payment of all sums that (hereafter called "THE COMPANY") now or hereafter owe Perrier Gems International, Inc. should the company default in payment of any sums due and payable to Perrier Gems International, Inc. I agree to pay Perrier Gems International,Inc. all such sums. I agree that my liability under this guarantee shall not be affected by any change in terms of payment from the company to Perrier Gems International, Inc.

Signature of Guarantor:

Print:

Date

Home Phone

Home address

City,State,Zip

Witness:

Print: