APPLICATION FOR ACCEPTANCE OF CUSTOMER'S CHECK	
YOUR INFORMATION	
Name of firm:	     	
Name of president or owner of business:	     	
Address:	     	Phone:	     	
City, State Zip:	     	Fax:	     	
No. of years in business under this name:	     		
Maximum amount being paid by check:	$     		
Signature:	     	Title:	     	Date:	     	
	
* Please have your bank furnishes the information requested below. We may ask bank for confirmation.	
BANK'S INFORMATION	
Name of bank:	     	
Address:	     	Phone:	     	
City, State Zip:	     	Fax:	     	
Checking account No.:	     	Open Date:	     	
Average balance:	$     	(In      months. Satisfactory? Yes      No    )	
Bank Officer’s signature:	     	Title:	     	Date:	     	
	
FOR CAPELLA USE ONLY		
Amount:	$	Approved by:		Date: