Print andFill it out completely and fax it to                                     ( OFFICE USE ONLY)   Acct. No.___________________

the fax number below.                                                                Terms ______________Salesman__________________

N&H Electronics, Inc.

Toll Free (800)264-8808     1100 Hardy Street, Hattiesburg, MS 39401   Fax (601)582-5572

CONFIDENTIAL DEALER APPLICATION

COMPANY NAME ________________________________________           DATE ___________________

BILLING ADDRESS ____________________________(ST/PO)_______________________(CITY/STATE/ZIP)

SHIPPING ADDRESS____________________________(ST)________________________(CITY/STATE/ZIP)

BUSINESS PHONE_(___)________________________ SALES TAX NO.__________________________

AUTHORIZED SIGNATURE FOR PURCHASING/SIGNING CHECKS _________________________________

OWNERS NAME _____________________________MANAGERS NAME____________________________

ADDRESS __________________________________ADDRESS___________________________________

CITY _________________STATE_____ZIP_______ CITY________________STATE_____ZIP_________

OWNERS RESIDENCE PHONE___________________ MANAGERS RESIDENCE PHONE_________________

PURCHASER AGREES IF SUIT OR PROCEDURE IS INSTITUTED BY SELLER TO EFFECT COLLECTION, PURCHASER WILL PAY REASONABLE ATTORNEY OR COLLECTION AGENCY FEES.  SELLER MAINTAINS A PERFECTED SECURITY INTEREST ON ALL GOODS SOLD UNTIL PAYMENT IN FULL IS RECEIVED.  TITLE OF GOODS TRANSFERS TO PURCHASER ONLY ON RECEIPT OF PAYMENT IN FULL.     A SERVICE CHARGE OF 1 1/2% PER MONTH WILL BE CHARGED ON THE BALANCE DUE ON ANY ACCOUNT OVER 30 DAYS.

NAME_____________________________TITLE____________SIGNATURE_________________________

DATE BUSINESS EST.__________________(CHECK ONE)DBA: CORP.( ) PARTNERSHIP( ) INDIVIDUAL( )

NOTE: IF PARTNERSHIP, ALL PARTNERS MUST SIGN APPLICATION (USE BACK IF NECESSARY)