PRIDE Truck Wash LLC New Charge Account Application

Legal Business Name: Contact Person: Billing Address: Street, Rt, PO Box City: State: Zip: Phone: ( ) Mobile: ( ) Fax: ( ) Company Information: # of trucks operating: Estimated # of trucks to be washed per month: If Individual Owner: Full Name: Street, Rt, P.O. Box: City: State: Zip: Phone :( ) Mobile :( ) If Partnership, List Partners: Full Name: Street, Rt, P.O. Box:

City: State: Zip: Phone #:( ) Mobile #:( )

If Corporation: Legal Corp. Name: Federal ID#: State of Incorporation: Date of Incorporation: / / Trader References (Accounts that have current credit standings with.) 1.) 2.)

1.) Name of Bank: Name of Bank: Street, Rt, P.O. Box: Street, Rt, P.O. Box:

City: State: Zip: City: State: Zip: 2.) Would you like to have a purchase order or authorization required for washing services? Yes No If yes, please list the phone number and contact person: ( ) - Name: Invoicing will be monthly by either mail fax_____ or email . Please mark which your prefer. Payment Terms: Net 30 days. After 30 days a 1.5% service charge will be added. 3.) The undersigned authorizes PRIDE Truck Wash LLC and attorneys to use the above information to check on business or personal credit standing. YOUR INFORMATION WILL REMAIN PRIVATE. Name (Printed): Signature: Date: / /

Please sign and fax the completed form to Lisa @ (270) 778-0004.

Or email to lisa@pridetruckwash.com Kentucky Kentucky Indiana Tennessee 13050 Walton Verona Road 1116 Cedar Grove Road 3570 E. 181

st Ave 1651 Everett Road

Walton, KY 41094 Shepherdsville, KY 41065 Hebron, IN 46341 Knoxville, TN 37932 I-75 Exit 171 I-65 Exit 116 I-65 Exit 240 I-40/75 Exit 369 (859) 485-6438 (502) 543-1911 (219) 696-4550 (865) 539-0035 Across the Street from Flying J Next to Love’s Truck Stop Across the Street from Flying J Across the Street from Flying J Next to Pilot Next to Quick Lube Next to Pilot Next to Speedco

Mail Payments To: PRIDE Truck Wash, LLC

PO Box 284 Franklin, KY 42135