SELECTEMP CREDIT APPLICATION	PRINT APPLICATION

GENERAL INFORMATION

COMPANY'S FULL LEGAL NAME

TELEPHONE NUMBER

ADDRESS

CITY

STATE

ZIP CODE

COUNTY

BILLING ADDRESS

CITY

STATE

ZIP CODE

COUNTY

PRINCIPAL OWNER OR OFFICER NAME

TITLE

CORPORTAION PROPRIETORSHIP PARTNERSHIP

NUMBER OF YEARS IN BUSINESS

TYPE OF BUSINESS

GOVERNING CLASS CODE

NUMBER OF EMPLOYEES

BANK REFERENCES

BRANCH/CITY

TELEPHONE

CONTACT

ACCOUNT #

CREDIT REFERENCES

CREDITOR NAME

ADDRESS

TELEPHONE

CONT. NAME

ACCOUNT #

CREDITOR NAME

ADDRESS

TELEPHONE

CONT. NAME

ACCOUNT #

CREDITOR NAME

ADDRESS

TELEPHONE

CONT. NAME

ACCOUNT #

The undersigned, agree to be bound by the Credit Agreement. If this agreement is executed on behalf of Customer, then the person executing and delivering this agreement on behalf of Customer represents and warrants that he or she is duly authorized to do so and that the execution and delivery of this agreement is the lawful and voluntary act of Customer. All information given above is correct to the best of the undersigned's knowledge. Customer authorizes Selectemp to verify any of the information given in the above application, and to check credit references and obtain one or more credit reports in connection with this application or in any periodic review of Customer's credit.

SIGNATURE

NAME (PRINTED)

TITLE

DATE

PLEASE SELECT THE BRANCH YOU WOULD LIKE TO SEND THIS APPLICATION TO (CHECK ALL THAT APPLY): Albany/Corvallis Eugene/Springfield Medford/Southern Oregon Salem