Company Information

*Company Name:

*Your Name:

All D/B/A Names:

*Phone:

Fax:

*Email:

Website:

Mailing Information

*Street Address:

*City:

*State:

*Zip:

Shipping Information

Street Address:

City:

State:

Zip:

Business Info

*Annual Rental Sales Revenue:

*Business Type: Partnership        Corporation

List Partners: - IF PARTNERSHIP

Incorporated In: (Year) (State) - IF CORPORATION

List Share / Shockholders

Name: Title:

Name: Title:

Name: Title:

References

*Bank: *Contact:

*Vendor:

*Vendor:

Purchase History

Agreement

Membership is open to all textile rental companies that meet the following criteria: Members shall not be companies that have stock or securities listed on a nationally recognized securities exchange or have stock or securities traded over-the-counter; Members shall not have gross revenue in excess of $150,000,000; Members shall not have gross revenues less than $500,000; No member shall have been the subject of an adverse determination in any governmental suit, hearing, investigation or proceeding, or any private suit, alleging unfair or fraudulent sales and/or marketing practices on part of a member; Members must satisfy Central States Corporation credit standards.

* I understand that the information provided in this document is for the sole purpose of qualifying my company for membership in Central States Corporation and will be held in strict confidence. I believe this information to be accurate.

*Are you human? (I'm trying to stop spam): Please Choose Nope, I'm a robot Yes, I'm human Nope, I'm a cyborg