For the purpose of obtaining merchandise from Gemico Inc. (Supplier) the following statements in writing are made knowing the Supplier is relying upon same as true and correct.It is further understood that the information as supplied is confidential and shall be regarded as continuous until another is substituted for it and the firm listed below agrees to inform Supplier of any material change in their financial status.


Corporate Name__________________________________ Trade Name_________________________________

Billing Address________________________________________________________________________________


Shipping Address______________________________________________________________________________


Tel # (†††† )____________________Fax # (††††† )_____________________Cellular(††††† )______________________

CHECK ONE:Corporation____Partnership___Sole Prop.___Other (specify)___________________________

Federal Tax # ______________________________ Resale Certificate # _________________________________

Type of Business______________________________________Date Started______________________________

State of Incorporation_______________________# of Stores___________# of Employees__________________

Officers, Partners or Owners:


Name & Title††††††††††††††††††††††††††††††††††††††††††††††† †††††††††††††††††††††††††††††††††††††††††††††††††Social Security #†††††† Driverís License #* (Copy must be attached)††


Home Address††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Home Tel #††††††††††††††††††††††††††††††††††††††††††† DOB†††††††††††††††††† Sex††††††††



Name & Title††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Social Security#††††††† Driverís License #*(Copy must be attached)


Home Address††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Home Tel #†††††††††††††††††††††††††††††††††††††††††††† DOB†††††††††††††††††† Sex


I, _________________________________ for and in consideration of your accepting checks or extending credit at my request to

___________________________________(herein referred to as the ďCompanyĒ) of which I am _____________________ (Owner, Manager, etc) hereby personally guarantee to you, Gemico Inc., the payment of any obligation of the Company, and I hereby agree to bind myself to pay you on demand any sum which may become due to you by the Company whenever the Company shall fail to pay the same.It is understood that this guaranty shall be a continuing and irrevocable guaranty and indemnity for such indebtedness of the Company.I do hereby waive the notice of default, non-payment and notice hereof and consent to any modification or renewal of the credit agreement hereby guaranteed.I further agree to pay any reasonable attorney fees and court costs incurred in any efforts to enforce payment of sums due by the Company, or to collect the same, governed by the laws of the State of Florida.


A$25.00 bank charge will be added to any account with a bounced check.

In the event of NSF or bad checks written to Gemico Inc. for goods ordered and shipped to the corporate name above, the undersigned authorizes Gemico Inc. to bill charges to following credit card #.


Type of Credit Card_________Credit Card #_________________________Name on Card_____________________ Expiry Date_________

Enclose copy of above current Master Card or Visa in the name of the Corporation, or personal card of Guarantor.


NOTICE:This Agreement must be signed and copies of Driverís License and Visa or Master Card attached before check approval or credit is extended.†† (Faxed copies will not be processed. Please send originals only)


Dated at ______________________ this ______day of ________________, _________

Company: _____________________________ Signature: ________________________

Title ________________________________ Print Name: ________________________

Creditor††††††††††††††††††††††† Gemico Inc.

By __________________________________††††††† Signature ______________________________