Please Submit the Application Via Fax at 1-450-420-1447 Or Email

Applicant’s Information Legal Business Name: Trade Name: Business Address: Phone #: Fax #: Federal Tax ID: Principal Officer: Started Business Date: Description of Business: Products you are interested in: Estimated Annual Purchase: Legal Organization Type: Proprietorship ___ Partnership ___ Corporation ___ Other (specify): Retail Only:___ Web Only:___ Retail and Web:___ Other:

Business / Trade References 1st Reference - Company Name: Address Phone # Fax # Email 2nd Reference - Company Name: Address Phone # Fax # Email 3rd Reference - Company Name: Address Phone # Fax # Email

Company/Applicant: hereby authorizes the release of information from trade references. Agreement: 1. I hereby certify that this information is complete and accurate to the best of my knowledge and belief. 2. By submitting this application, you authorize RobotShop Inc to make inquiries into the business/trade references that you have supplied. Authorized Officer name and signature:

Date: Please submit the application via fax at 1-450-420-1447 or email [email protected]