Euro-American Enterprises, L.L.C.

Post Office Box 28178 Bellingham, Washington 98228

Telephone: (360) 734-3195 Facsimile: (360) 734-2647

sales@euroamericanenterprises.com

AUTHORIZED DOMESTIC U.S. DEALER APPLICATION FORM

(Exhibit "D" to EAE Dealer Distribution Agreement)

Please send this form when completed to Euro-American Enterprises, L.L.C. by facsimile at (360) 734-2647, and/or as an attachment to an e-mail to sales@euroamericanenterprises.com. Information provided will be treated as confidential in nature and will not be disclosed to any third parties.

1.

GENERAL INFORMATION

Telephone:_____________

Company Name:___________________________________________

Facsimile:______________

Address: _________________________________________________

_________________________________________________________

E-Mail:_________________

Invoice Address if different than above:________________________ _________________________________________________________

Website:_______________

Years in Business:_______

Sales or Use Tax Exemption Number:__________________________

Federal Employer Identification Number: _______________________

Number of Employees:___

2.

IDENTIFICATION OF PRINCIPAL OWNERS AND MANAGERS

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

(Full Name)

3.

MARKET AND TRADE REFERENCES

-

Please identify Two (2) firms whose products you now distribute

______________________________________________________________________________

(Mailing Address)

(Fax and Telephone Number)

(Firm Name)

______________________________________________________________________________

(Purchasing Terms)

(Years Associated With)

______________________________________________________________________________

______________________________________________________________________________

(date)

(Person to Contact)