Corporate Account Application
BreatheWear Inc. 2451 Cumberland Pkwy Suite 3171 Atlanta, GA 30339

Billing Address: Shipping Address:
Name: Name:
Address 1: Address 1:
Address 2: Address 2:
City: City:
State: State:
Zip: Zip:

Company Information Names Of Company Officers Title
Date Firm Started: 1)
Federal Tax ID#: 2)
Tax Exempt: 3)
State: Zip:
Phone: Fax:
Email Address:

Trade References:
Company Name: City, State Phone

By entering my typed name, initials and date, I authorize BREATHEWEAR, INC. to verify the company history and information provided on this form to extend a line of credit for purchases under credit terms of NET 30 days as stated on invoices. We authorize BREATHEWEAR, INC. to contact the references listed above. We understand all this information will be held in strict confidence and will be used only for the consideration of extension of credit. We agree to pay a service charge of 1/5% per month on any amounts that become past due and will pay all costs associated with any legal action in addition to reasonable collection and attorney fees resulting from such action.

Applicant Full Name:
Applicant Initials:

Please enter the following code into the box provided: