Dilmaghani - 540 Central Park Avenue, Scarsdale, NY 10583 (914) 472-1700 --------Fax (914) 472-5154

APPLICATION FOR DESIGN FIRM ACCOUNT - PAGE 1 of 2
Company Name____________________________________________________________ Attention/Contact ___________________________________________________________ Mailing Address ____________________________________________________________ Shipping Address ___________________________________________________________ City ____________________________State ______________ Zip ___________________ County where business is located ________________________________________ Office Telephone No. (_____) _____-_________ Fax No.(_____) _____-_________ Federal ID No. ______________________ Resale No. _____________________ State______ (SSN for individuals) Profession: [_] Interior designer [_] Architect [_] Facility Planner [_] other:____________________ Professional Association: [_] AIA [_] ASID [_] FASID [_] IBD [_] ISID [_] ABT
ORGANIZATION
[_] Corporation [_] Partnership [_] Proprietership [_] Individual [_] Other____________________ Date of Formation/Incorporation _______________, 19____ State of ________________ List name / address / telephone No. of all officers, partners, owners or principals. Title----Name-----------------------------Home Address ----------------------City--------------------State----Zip-----------------Area----------Home Phone ___ _____________ ________________ ___________ ___ _______ (____) ____ ______ ___ _____________ ________________ ___________ ___ _______ (____) ____ ______ ___ _____________ ________________ ___________ ___ _______ (____) ____ ______ ___ _____________ ________________ ___________ ___ _______ (____) ____ ______ ___ _____________ ________________ ___________ ___ _______ (____) ____ ______
FACILITIES
Showroom Address (if different from above) address______________________ city___________ state_____ zip______ Phone(___) ___-_____ Please describe your type of business/products/services: _________________________________________________________________ Other products: [_] Carpeting [_] Machine Made Rugs [_] Furniture [_] Fabrics [_] Other______________ Landlord of business premises: _________________________________ Phone(___) ___-_____ Branch Location Address __________________________________________________ Landlord of Branch Location __________________________________ Phone (____) ____-_______
APPLICATION FOR DESIGN FIRM ACCOUNT - PAGE 2 of 2
TRADE REFERENCES (Suppliers/Vendors)  _________________ ________________ Vendor Name _________________ ________________ Address _________________ ________________ City/St/Zip (____) ____-________ (____) ____-________ Vendor's Phone ---------------------------- Fax __________________________ __________ Acct # with Vendor ----------------------------------------- # Years _________________________________________________ Contact at Vendor Company  _________________ ________________ Vendor Name _________________ ________________ Address _________________ ________________ City/St/Zip (____) ____-________ (____) ____-________ Vendor's Phone ---------------------------- Fax  __________________________ __________ Acct # with Vendor ----------------------------------------- # Years _________________________________________________ Contact at Vendor Company  _________________ ________________ Vendor Name _________________ ________________ Address _________________ ________________ City/St/Zip (____) ____-________ (____) ____-________ Vendor's Phone ---------------------------- Fax  __________________________ __________ Acct # with Vendor ----------------------------------------- # Years _________________________________________________ Contact at Vendor Company
BANK REFERENCE
_________________ ________________ Bank Name _________________ ________________ Address _________________ ________________ City/St/Zip (____) ____-________ (____) ____-________ Bank's Phone ------------------------------- Fax  __________________________ __________ Acct # with Bank---------------------------------------------- # Years _________________________________________________ Contact at Bank
CERTIFICATION
I, ______________________________(individual), certify that I am the _______________(title) of ___________________________________(name of business entity) and that all of the information and representations contained herein are true and submitted for the purpose of obtaining credit. Signature ____________________________ Name Printed __________________________ Title _____________ Date (__/__/_____)
Return original by mail to: DILMAGHANI - 540 Central Park Avenue - Scarsdale - NY - 10583