RE: EAE Commissioned Representative Application Form

Page 2

REPRESENTATIVE:__________________________

PREPARED BY:__________________________

4.

MARKETING DATA

Number of Salesman Currently in the Firm:_____

Annual Sales Volume:________

Do You Now Sell to a Dealer Base?_______

Actual Sales Territory Desired:__________________________________________________________________

Mail:____ Over the Road:____

Method of Sales You Currently Utilize (Please check all applicable boxes):

Catalog:____ Sales Associates:____ Internet:____ Mail :____ Fax on Demand:____ OTHER:____________

Customers You Now Call On (Please check all applicable boxes): Dealers:_____ Government:__________

Wholesale Distributors:____ Institutional Customers____ Industrial Users ____ Factory Outlets________

Trade Shows that you attend or participate in:_____________________________________________________

Do You take or share booth space at any shows listed above?______

(If Yes, Please circle the shows above)

Primary reason(s) you attend trade shows: (Please check all applicable boxes) To find new lines:_______

Check our competitive lines:___ Selling Current lines:___ Introducing new products:___ Write orders:___

Do you maintain any retail point of purchase sales displays?_____

If yes, who owns displays?__________

Type of Advertising You Do:

(Please check all applicable boxes)

Local Newspaper: _____ National Magazines:____

Television:_______ Radio:_______ Brochures:_______ Mailers:_______ Catalogs:_______ OTHER:________

______________________________________________________________________________________________

______________________________________________________________________________________________

Do you currently own or lease any warehouse space? If yes, how many square feet?___________________

Do You Warehouse inventory for any of your sales lines?___ (Y/N) If yes, who owns inventory?___________

Do you ever issue Purchase Orders for your client base:___ (Y/N)

Your current inventory value: $________

If Yes, Name(s)/Title(s) of those authorized to sign Purchase Orders: _________________________________

6.

ADMINISTRATIVE DATA

Type of Business:

(Please check all applicable boxes)

Corporation:_____ Partnership:_____ Sole Proprietor:_____

Limited Liability Company:_____ State of Incorporation (if applicable) _______________ OTHER:_________

7.

AUTHORIZATION TO REVIEW

It is understood that if this application is favorably reviewed and approved by Euro American Enterprises, L.L.C.(hereinafter "EAE") that our firm will be required to sign a basic Commissioned Representative Agreement before being able to receive commissions. It is further understood that EAE, and/or its agents, may be required to verify the information contained in this application before approval. Consistent with that understanding, I/WE herewith authorize EAE to make any inquiries it deems necessary in this instance. Further, I/WE herewith release EAE from any liability it may incur as a result of its efforts to reasonably investigate the claims or statements made herein.

SIGNATURE OF AUTHORIZED OFFICIAL:____________________________________

DATE:____________

PRINTED NAME:_______________________________________________

TITLE:______________________