Newark Asphalt Corp.  Logo
Tel: (973) 482-3503    Fax: (973) 268-3639

The following information is submitted as a basis for the extension of credit. (* indicates a required field.)
* Individual or Company Name:
* Physical Address:
* Mailing Address:
* City: * State: * Zip Code:
* Phone:   Fax:  
* Email:        
* Type of Business: * Federal ID:  
* Year Established: * State:  
* We are at this location since: (year)        
* Type of ownership:  Corporation  Partnership   Limited Partnership  Individual

Principal owners or stockholders and officers are:
1. * Name: * Title: * Address:
  * City: * State: * Zip Code:
2.   Name:   Title:   Address:
    City:   State:   Zip Code:

* Principal's home phone number: * Principal Name:
* Cell:   Fax:
* Email:      

Financial Information:
* Name of Bank:    
* Address:    
* Acct.#:    
* Contact:    
* Phone: Fax:

Trade References: (Please Type)
* Name: * Address: * Phone: Fax:
  Name:   Address:   Phone: Fax:
  Name:   Address:   Phone: Fax:

Newark Asphalt Corp. may verify the above reference and any other information to determine credit capacity.
Our current terms: Net 30 days, finance charge of 1-1/2 precent per month (18% per annum) will be applied to the net amount outstanding as of the 30th of each succeeding month after 60 days.

Newark Asphalt Corp. is hereby authorized to extend credit to the above named firm and the undersigned guarantee payment, individually and collectively. In the event of any default as a result of which Newark Asphalt Corp. must retain counsel or bonded collection agency, costs will be added to the bank due.

(Please Type and Sign)
Name ____________________________________   Signature ______________________________________  Date ____________________ 

Approved by ________________________________________  Date _________________________   Credit Limit ______________________


Bank Release Form

Please fill and sign the statement below, which will be sent or faxed to your bank. Your permission is required to
access account information. This will expedite the processing of your credit application.

I,_______________________________________ give ______________________________________________
(Company Official) (Bank Name)

permission to release account information to Newark Asphalt Corp. for the purpose of obtaining credit.

Thank You.

Signature and Date


Account Number

*Company Officer name
*Bank Name