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GEORGE & COMPANY LLC		Credit Dept.
P.O. Box 111898	Naples, FL	34108
Phone: 239-949-3650		Fax: 239-949-3653
LCR®/Left Center Right™ Dice Game

New Account Application

To purchase our products at wholesale price, complete this application and click the button below to send it. If requesting that we extend to you terms of 30 days, please include a current list of business references and allow 2-3 weeks for approval. Otherwise your order will go out C. O. D., or payment in advance. Applications with missing information or without a valid license will be considered incomplete and no order will be shipped. 1st order must be a minimum quantity of 48 games. Thank You.

State:	Vendor/Tax Identification #:
Federal:	EIN #:

Date:
Company Name:
Contact Person:		Phone:

	Business Shipping Address:
Address/P.O. Box:
City:
State:		Zip Code:
Phone:
Fax:
	Type of Business:

	Business Billing Address:		Same as Shipping
Address/P.O. Box:
City:
State:		Zip Code:
Phone:
Fax:
	Website Address:

If you wish to expedite your order, you may provide your credit card information below.

Card Type:
Credit Card #:		Exp. Date:

Check this box if applying for Net 30 terms. Please include a list of business references with up-to-date company information and fax numbers, and allow 2-3 weeks for approval.

	Business Reference 1:
Company Name:
Contact Person:
Address/P.O. Box:
City:
State:		Zip Code:
Phone:
Fax:

	Business Reference 2:
Company Name:
Contact Person:
Address/P.O. Box:
City:
State:		Zip Code:
Phone:
Fax: