1324 Cavalier Boulevard

Chesapeake, VA 23323

Phone (757) 487-8725 Fax (757) 487-8621

nacm@nacmhamptonroads.com

DATE_________________________________

FIRM NAME___________________________________________________________ SIC CODE (If known) __________________

TYPE OF BUSINESS_________________________________________________________________________________________

MAILING ADDRESS_________________________________________________________________________________________

PHYSICAL ADDRESS________________________________________________________________________________________

PHONE # ( ) ________ - ________________ (800) ______ - _____________ FAX ( ) __________ -______________

E-MAIL ADDRESS___________________________________________________________________________________________

CREDIT MANAGER__________________________________________________________________________________________

CREDIT REFERENCE CONTACT_____________________________________________TIME TO CALL____________________

IMMEDIATE SUPERVISOR___________________________________________________TITLE___________________________

BILLING ADDRESS__________________________________________________________________________________________

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For billing purposes - Please check & complete appropriate boxes

[ ] ANNUAL MEMBERSHIP DUES $__________________ [ ] ASSOCIATE MEMBERSHIP DUES $___________________

[ ] CREDIT GROUP (optional) __________________________________________________ GROUP DUES $________________

Name of Group

GROUP REPRESENTATIVE___________________________________________________ TITLE_________________________

[ ] FLASH REPORT (optional) $______________________ TOTAL OF SERVICES $___________

[ ] I AM INTERESTED IN INFORMATION ABOUT DIRECT ACCESS TO YOUR LOCAL FILES.

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We hereby make application for membership in the National Association of Credit Management-Hampton Roads, Inc. for a period of one year and continuing from year to year thereafter unless notice of cancellation in writing is given at least 30 days in advance.

When accepted I agree to:

1. Furnish ledger information and pertinent comments accurately and as quickly as possible.

2. Keep all credit information strictly confidential for credit purposes

only. And, never disclose the contents of a report to the subject.

3. Abide by the By-Laws of the Association and its service division rules

as may be amended from time to time.

DATE_______________________________SIGNATURE__________________________________________________________

DATE________________________ NACM REPRESENTATIVE____________________________________________________