Wholesale Application Form

*Company Name:

*Contact Name:

*Address:

*City:

*State:

*Zip Code:

*Country:

*Phone:

Fax:

*Email Address:

Alternate Contact Name:

Alternate Phone(or cell):

Store's Website URL:

You must provide your State Resale Tax ID number before we can ship goods to you at wholesale prices:

*Resale Tax ID #:

Preferred Payment Method:

Note: When ordering online you can submit a credit card securely. If you order via phone or fax, you can submit your credit card information at that time as well.

SEND FIRST ORDER COD

Check this box, if you want your 1st order sent COD. There will be a COD Charge added to your order's total. Please be aware that should you refuse to accept the COD package for any reason, you must pay by credit card for any future orders.

SEND NET 30 DAY TERMS

Check this box if you will be requesting Net 30 Terms with us for future orders. If you want terms, please print, fill out and snail-mail or fax the Nusantara Credit Application for Net 30 Day Terms to us. Please ensure that you have provided three credit references with up-to-date contact information.

The following box must be checked in order to successfully complete the registration process:

* I understand that there's a $100 Minimum Order for first-time buyers, and a $50.00 minimum for all subsequent orders.

* Denotes required field

| Nusantara | 43 Strongs Ave Rutland Vermont 05701 | Telephone: 802.775.3027 - Fax: 802.773.0786 |

| www.nusantarawarehouse.com | www.nusantarainc.com |