TRADE REFERENCES
Name: _________________________________ Name: ________________________________
Address: ______________________________ Address: _____________________________
City: _________ State: _____ Zip: ________ City: _______ State: _____ Zip: ____________
Tel: __________________ Fax: ____________ Tel: _________________ Fax: __________
Acct Number:_______________ Acct Number: _____________

Name: _________________________________ Name: ________________________________
Address: ______________________________ Address: _____________________________
City: _________ State: _____ Zip: ________ City: _______ State: _____ Zip: ____________
Tel: __________________ Fax: ____________ Tel: _________________ Fax: __________
Acct:___________________ Acct Number:________________
BANK REFERENCES
Name: ________________________________ Name: ________________________________
Address: ______________________________ Address: __________________________
City: _____________ State: ______ Zip: _____ City: ____________ State: ______ Zip: _____
Tel: ______________ Fax: _____________ Tel: ______________ Fax: _____________
Acct:____________________ Acct:________________________

Lifestyle Mobility Aids is hereby authorized to obtain credit history information from the above references for the purpose of reviewing for a dealership.
Signature: ________________________________ Title: _____________________________________

Print Name: _______________________________ Date: _____________________________________

PERSONAL GUARANTEE
I,____________, hereby personally guarantee any and all credit extended to my company. I will be personally responsible and liable for all balances due, including costs of collection, should that become necessary.
Signature:_________________________________ Print Name: _______________________________________
Home Address: _______________________________ Home Phone #:_________________ Date:____________