Euro-American Enterprises, L.L.C.

Post Office Box 28178 Bellingham, Washington 98228

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

sales@euroamericanenterprises.com

DOMESTIC U.S. COMMISSIONED REPRESENTATIVE APPLICATION FORM

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

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

3.

REFERENCES

- Please Identify Four (4) Lines or Companies whose products you represent(ed):

_____________________________________________________________________________________________

(Name of Firm)

(Personal Contact & Telephone Number)

(Years With)

(Annual Sales Volume $)

_____________________________________________________________________________________________

(Name of Firm)

(Personal Contact & Telephone Number)

(Years With)

(Annual Sales Volume $)

_____________________________________________________________________________________________

(Name of Firm)

(Personal Contact & Telephone Number)

(Years With)

(Annual Sales Volume $)

_____________________________________________________________________________________________

(Name of Firm)

(Personal Contact & Telephone Number)

(Years With)

(Annual Sales Volume $)

OTHER REFERENCES:_________________________________________________________________________