Company:_____________________________________________________________

D.B.A.:_______________________________________________________________

Address:______________________________________________________________

City, State, Zip:_________________________________________________________

Telephone:______________ Fax:________________ Email:_____________________

Federal Tax I.D.#:_________________ Number of Years in Business:_____________

Name of Person Filling this form:__________________ Title:_____________________

Social Security # of person filling this form:____________________________________

Circle one:            Corporation            Partnership           Sole Proprietorship     LLP    LLC

Bank Name:______________________ Bank Account Number:___________________

Bank Officer:___________________________________________________________

References (Please include telephone, contact person, and your account number):

1._________________________________________________________________________            

2._________________________________________________________________________            

3._________________________________________________________________________            

4._________________________________________________________________________            

The undersigned has applied for credit with Ninacci Inc. and hereby authorizes
the release of any and all credit information which may be required to process this credit application.

_____________________________________            ___________________________
Signature                                                                                Date