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For your application to be considered, all blanks must be completed.

Name/Address
Last Name: First Name: Middle Initial: Title:
Name of business
Please enter your company name.		 Tax ID Number:
Address: Email Address: A value is required.Invalid format.
City: State: Zip Code: Phone 1:
Phone 2:

Company Information
Type of Business: In Business Since:
Legal Form Under Which Business Operates: Corporation Partnership Proprietorship LLC Please make a selection.
If Division/Subsidiary, Name of Parent Company: In Business Since:
Name of Person Responsible for Business Transactions: Title:
Address: City State: Zip: Phone:
Name of Person Responsible for Business Transactions: Title:
Address: City State: Zip: Phone:

Bank References
Institution Name
Checking Account #:
Address:
Phone:
Institution Name
Savings Account #:
Address:
Phone:
Institution Name
Home Equity Loan #:
Address:
Phone:

Trade References
Company Name
Contact Name:
Address:
Phone:
Account Opened Since:
Credit Limit:
Current Balance:
Company Name
Contact Name:
Address:
Phone:
Account Opened Since:
Credit Limit:
Current Balance:
Company Name
Contact Name:
Address:
Phone:
Account Opened Since:
Credit Limit:
Current Balance:

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this Distributor Application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein.


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New York Spring Water, Inc.
517 W 36th Street
NY, NY 10018
Tel: (212) SpringWater
information@newyorksprings.com

Copyright 2007 New York Spring Water, Inc.

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