PRIMARY INFORMATION:

BUSINESS NAME: MARKETING #

TRADE NAME (S):

MAIN BUSINESS ADDRESS:

PRINCIPAL(S) NAME(S):

OTHER LOCATIONS:

PHONE#: HOW LONG IN BUSINESS:

TYPE OF BUSINESS/PRINCIPAL PRODUCT SOLD (INCL. BRAND NAME IF APPLICABLE)

</textarea;?> </p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>RESALE NO. <input type="text" name="textfield10"> FEDERAL ID#: <input type="text" name="textfield11"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>AUTHORIZED DEALER FOR:<br> </span><span style='font-size:10.0pt;font-family:Arial;color:#003399';?> <textarea name="textfield12" cols="80"></textarea;?> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>CONTACT NAME <input type="text" name="textfield13"> CONTACT PHONE #: <input type="text" name="textfield14"> </span></p></td> </tr> <tr> <td height="36" valign=middle class="Normal"> </td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?><strong>BROKER INFORMATION:</strong></span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>HOW LONG DEALT WITH VENDOR? <input name="textfield15" type="text" size="16"> NUMBER OF TRANSACTIONS COMPLETED: <input name="textfield16" type="text" size="16"> </span></p></td> </tr> <tr> <td width=767 height="24" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?><br> COMMENTS: <br> <textarea name="textfield17" cols="80"></textarea;?> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>BROKER/LESSOR: <input type="text" name="textfield18"> </span></p></td> </tr> <tr> <td height="36" valign=middle class="Normal"> </td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?><strong>PRINCIPAL(S) SECTION:</strong></span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>NAME: <input type="text" name="textfield19"> SSN: <input type="text" name="textfield20"> TITLE: <input type="text" name="textfield21"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>ADDRESS: <input type="text" name="textfield22"> CITY: <input type="text" name="textfield23"> STATE: <input name="textfield24" type="text" size="4"> ZIP: <input type="text" name="textfield25"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>NAME: <input type="text" name="textfield26"> SSN: <input type="text" name="textfield27"> TITLE: <input type="text" name="textfield28"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>ADDRESS: <input type="text" name="textfield29"> CITY: <input type="text" name="textfield30"> STATE: <input name="textfield31" type="text" size="4"> ZIP: <input type="text" name="textfield32"> </span></p></td> </tr> <tr> <td height="36" valign=middle class="Normal"> </td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?><strong>BANK SECTION:</strong></span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>PRIMARY BANK: <input type="text" name="textfield33"> BRANCH: <input type="text" name="textfield34"> PHONE #: <input type="text" name="textfield35"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>CONTACT OFFICER: <input type="text" name="textfield36"> ACCOUNT #: <input type="text" name="textfield37"> </span></p></td> </tr> <tr> <td height="36" valign=middle class="Normal"> </td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?><strong>SUPPLIER SOURCES & LANDLORD:</strong></span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>COMPANY : <input type="text" name="textfield38"> CONTACT: <input type="text" name="textfield39"> PHONE: <input type="text" name="textfield40"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>COMPANY : <input type="text" name="textfield41"> CONTACT: <input type="text" name="textfield42"> PHONE: <input type="text" name="textfield43"> </span></p></td> </tr> <tr> <td width=767 height="36" valign=middle class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?>LANDLORD: <input type="text" name="textfield44"> CONTACT: <input type="text" name="textfield45"> PHONE: <input type="text" name="textfield46"> </span></p></td> </tr> <tr> <td width=767 valign=top class="Normal"> <p><span style='font-size:10.0pt;font-family:Arial;color:#003399';?><br> BROKER/LESSOR eMAIL FOR SIGNATURE: <input type="text" name="textfield47"> </span></p></td> </tr> </table> <p> <input type="submit" name="Submit" value="Submit"> <input type="reset" name="Submit2" value="Reset"> </p> </form;?></td> </tr> </table> <!-- End content block --></td> <!-- SPACER --> </tr> <tr> <td height="49" > </td> <td > </td> </tr> </table> </td> </tr> </table> <table border="0" cellpadding="0" cellspacing="0" width="100%"> <tr> <td background="/test/logo/flag_strip_bg2.jpg" width="40%"> <img src="/test/logo/flag_strip_bg2.jpg" border="0"></td> <td>  </td> <td align="center" valign="bottom" nowrap> <font face="Arial,Helvetica,Sans Serif MS" size="3"><b> <i>Call Performance Capital today (866)334-5556</i></b></font> <br><span class="style12ca"><font size="2"> <a href="/corp/terms_conditions.htm">Terms & Conditions</a> | <a href="/corp/privacy.htm">Privacy</a> | <a href="/corp/security.htm">Security</a> </font></span> <br><br> </td> <td>  </td> <td background="/test/logo/flag_strip_bg2.jpg" width="40%"> <img src="/test/logo/flag_strip_bg2.jpg" border="0"></td> </tr> </table> <center> <span class="style12ca"><font size="2"> Copyright © 2010 Performance Capital Corporation, all rights reserved. </font></span> </center> <br><br> </body> </html>