Allan A. Goldman Inc. - Direct Importers of Fine Gemstones Since 1955

Please print and fax this application to 212-869-3080

Date: _____________________

Firm Name: ________________________________________________________________________

Street Address:_____________________________________________________________________

City, State, Zip _____________________________________________________________________

Phone #: ________________ Fax #: _______________ Tax Exempt Resale #: _________________

Type of Business: ____________________________________ # Of Years In Business __________

Jewelers Board of Trade Rating __________________ Email _______________________________

Please circle one: Corporation Partnership Sole Proprietorship

Principals: Please list names and titles of officers, partners or owner.

Name: ____________________________________________ Title: ___________________________

Bank References:

Bank Name: _________________________________________ Phone: _______________________

Address:__________________________________________________ Zip: ____________________

Account Number: _________________________ Acct. Exec: _______________________________

Trade References:

1. Firm: __________________________________________ Phone #: ______________________

1. Address: ______________________________________________________________________

2. Firm: __________________________________________ Phone #: ______________________

1. Address: ______________________________________________________________________

3. Firm: __________________________________________ Phone #: ______________________

1. Address: ______________________________________________________________________

GUARANTEE

ALL TERMS ARE NET 30 DAYS.
NO RETURNS AFTER 30 DAYS OF ITEMS BILLED BY INVOICE DATE.
It is understood that all invoices paid late will be penalized at 1.5% per month (18% annual).
In the event that Allan A. Goldman Inc. must access legal action to obtain moneys owed,
it is understood that the debtor will be responsible for any legal or collection fees that
are incurred as a result.

Having filled out the above application and agreeing with the above guarantee please sign below:

_____________________________________ _________________________ ________________
Principal's individual signature Title Date