Brekke Storage                                               
                                                               105 3rd Ave
                                                         Longmont, CO 80501
                                                              303-776-2610


Customer/Company Information:

Name:_______________________________________        Contact Name:______________________________  Title:__________________________

Address:_____________________________________     City:_____________________________ State:______________ Zip:___________________

Phone:________________________________ Fax:___________________________  Federal Tax ID#:_______________________________________

A/P Contact:________________________________ Phone:__________________________  Fax:_____________________________

PO Required:      Yes       No


Trade Reference:


Reference #1

Company Name:__________________________________________________     Contact Name:___________________________________________

Address:___________________________________________________________________________________________________________________  

Phone:___________________________________   Fax:_____________________________           Account #:________________________________

Reference #2

Company Name:__________________________________________________     Contact Name:___________________________________________

Address:___________________________________________________________________________________________________________________  

Phone:___________________________________   Fax:_____________________________           Account #:________________________________

Reference #3

Company Name:__________________________________________________     Contact Name:___________________________________________

Address:___________________________________________________________________________________________________________________  

Phone:___________________________________   Fax:_____________________________           Account #:________________________________


Bank Reference


Name:___________________________________________  Contact Name:____________________________ Account#:________________________

Address:_____________________________________________________________________  Phone:___________________ Fax:_________________


Insurance Information


Name:________________________________________________ Agent's Name:______________________________ Policy #:___________________

Address:____________________________________________________________________________________________________________________

Phone:____________________________________  Fax:___________________________________


My signature below hereby give authorization to Brekke Storage to do a trade reference credit check, bank reference, credit history on this company:


Signature_____________________________________________________________ Print Name:___________________________________________

Personal Guarantee     Yes     No                                                                           Title/Date:____________________________________________


To hvae a credit card billed monthly:

Sign Here (as it appears on the card)_________________________________________________  Credit Card Type        Visa    M/C

Name on Card:_________________________________________________  Number:_____________________________________________________

Expiration Date:__________________ 3 Didgit Security Code:_________ (code is located on the back of the card after the account number)


                                                                    Print and Fax to 303-651-7633