DATE:_______________________

ISSUED TO: Cross Bros. Co.

FIRM NAME: (NAME OF FIRM REQUESTING STATEMENT)
___________________________________________________________________________________

MAILING ADDRESS: _____________________________________ PHONE:_____________________

CITY: __________________ STATE: ______________ ZIP CODE: _____________________________

FULL NAME OF OWNER OR OWNERS (OR AN AUTHORIZED OFFICER OF CORPORATION)
LIST HOME ADDRESS & ZIP CODE FOR PARTNERSHIP OR INDIVIDUAL.
1._________________________________________________________________________________

2._________________________________________________________________________________

DEBTOR INDIVIDUAL SIGNING CONTRACT: ______________________________________________

TITLE:___________________________________

DEBTORS SOCIAL SECURITY NO: (FOR PARTNERSHIP OR INDIVIDUAL)_____________________

TYPE OF BUSINESS __________________________________

DATE STARTED_______________________

WE EXPECT OUR MONTHLY CREDIT REQUIREMENTS FROM YOU TO BE ABOUT $______________________

FORMER BUSINESS ________________________________ LOCATION ______________________

OWN OR RENT BUILDING - IF RENT, FROM WHOM?_______________________________________

REAL ESTATE MORTGAGE:____________________________________________________________

NAME MAILING ADDRESS CITY STATE ZIP

1)___________________________________________________________________________________

2)___________________________________________________________________________________

3)___________________________________________________________________________________