ph. 702-736-6478 fax 702-597-2865

email Rocky@coolworldinc.com

New Distributor Application DATE ____________________

BUSINESS LOCATION / INFORMATION

NAME OF BUSINESS

PHONE

LEGAL (IF DIFFERENT)

FAX

ADDRESS

CITY

WEB SITE

STATE ZIP

DIGITAL

COUNTRY

OTHER

DESCRIPTION OF BUSINESS

TYPE OF BUSINESS

IN BUSINESS SINCE CREDIT REQUESTED $ NUMBER OF EMPLOYEES YEARLY SALES $

BUSINESS STRUCTURE : ___ CORPORATION ___ PARTNERSHIP ____ PROPRIETORSHIP ____ DIVISION / SUBSIDIARY

PROJECTED ANNUAL ORDER

COMPANY PRINCIPALS RESPONSIBLE FOR BUSINESS

NAME TITLE ADDRESS PHONE

BANK REFERENCES

NAME OF BANK

CONTACT PERSON

BRANCH

ADDRESS

CHECKING ACT. #

WIRE TRANSFER

PHONE

FAX

TRADE REFERENCES

FIRM NAME CONTACT NAME PHONE ACCOUNT OPEN SINCE

CONFIRMATION OF INFORMATION ACCURACY AND RELEASE OF AUTHORITY TO VERIFY

I hereby certify that the information in this application is correct. The information included in this application is for use by Nevada Mist in determining the suitability of the applicant as a distributor of Nevada Mist. I understand that Nevada Mist may also utilize other resources considered necessary in making this determination . Further I hereby authorize bank and trade references in this application to release the information necessary to assist Nevada Mist in establishing the suitability for distributor status.

___________________ _____________________ _____________________

SIGNATURE TITLE DATE