New Account Profile

1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com

New Customer Account – Profile Template March 2021 When bringing a new Customer onboard, this package must be completed as outlined below. Failure to complete this package may result in delays with the account being opened.

Section 1 – New Customer Profile Information (pgs 2 - 4) This section is to be completed by the PureCare Sales Rep. Once this section is received by PureCare, a member of the Operations team will review all information and enter this customer into our ERP.

These completed pages must be emailed to newaccounts@purecare.com when completed

Section 2 – New Customer Financial Information (pgs 5 - 7) This section is to be completed by the New Customer.

Once this section is received by PureCare, PureCare will review all information and establish credit terms accordingly (if applicable). This process takes approximately 5 business days to check credit and business references All new customers must also include a State Resale Certificate to PureCare

This completed form must be emailed to newaccounts@purecare.com and your PureCare Sales rep when completed

NOTE: A sales order for PureCare product may be submitted at the same time you submit this completed New Customer Account Profile. However, it will not be entered into our system for shipping until all sections have been reviewed and the account approved.

An order for POP products may be submitted at the same time you submit this completed New Customer Account Profile. However, it will not be entered into our system for shipping until all sections have been reviewed and the account approved.

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1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com

Customer Information

PureCare New Customer Account – Profile Information To be Completed by the PureCare Sales Rep

Legal Company Name ______________________________________Website Address _________________________________ D.B.A. ___________________________________________________ Number of Locations ________________________________ Would this customer like to be listed on the www.PureCare.com dealer locator? _______________________ Bill to Address ________________________________________ City/State/Zip ___________________________________________ Ship to Address ________________________________________ City/State/Zip _________________________________________ Phone Number ________________________________________________________________________________________________

Customer Pricing …… Nationwide Pricing …… Base Pricing …… A Pricing (Nationwide # required) __________________ …… Other (requires written or email approval from Jeff Bergman) Warehouse/Delivery Locations If there are more than 5 locations, please provide a complete list in a separate document for PureCare records

Warehouse Location #1 Address ________________________________________ City/State/Zip _______________________________________ Phone #1 ________________________ Phone #2 ____________________________ Fax # ________________________ Warehouse Location #2 Address ________________________________________ City/State/Zip _______________________________________ Phone #1 ________________________ Phone #2 ____________________________ Fax # ________________________ Warehouse Location #3 Address ________________________________________ City/State/Zip _______________________________________ Phone #1 ________________________ Phone #2 ____________________________ Fax # ________________________ Warehouse Location #4 Address ________________________________________ City/State/Zip _______________________________________ Phone #1 ________________________ Phone #2 ____________________________ Fax # ________________________ Warehouse Location #5 Address ________________________________________ City/State/Zip _______________________________________ Phone #1 ________________________ Phone #2 ____________________________ Fax # ________________________ Page 2 of 7

1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com Miscellaneous Account Information Products Being Sold By Customer: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Approximate Date of First Order: _________________________________________________________________________________________________ How Will Orders Be Given To PureCare? _________________________________________________________________________________________________ Warehouse Receiving Days and Hours of Operation: _________________________________________________________________________________________________ _________________________________________________________________________________________________

Container Direct Customer? check one …… all orders ship direct from factory to customer …… all orders ship from PureCare warehouse PureCare POP/Promotional Materials needed? …… YES …… NO (if yes, attach POP Sample Order form) If custom-designed POP/Promotional Materials are needed, they will need to be created with the PureCare Marketing Team. Please contact the PureCare Marketing Team for more details.

Date POP/Promotional Materials are needed by Customer?_______________________________________ Additional POP / Promotional Materials Comments/Remarks: _________________________________________________________________________________________________ _________________________________________________________________________________________________ Additional Comments/Remarks: _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Page 3 of 7

1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com

Department Contact Information Primary Contact Name __________________________________________ Title or Position ______________________________ Email ________________________________________________________________________________________ Contact Phone #1 ________________________________ Contact Phone #2 ___________________________ Contact Fax # ___________________________________ Purchasing Contact Name __________________________________________ Title or Position ______________________________ Email ________________________________________________________________________________________ Contact Phone #1 ________________________________ Contact Phone #2 ___________________________ Contact Fax # ___________________________________ Accounting Contact Name __________________________________________ Title or Position ______________________________ Email ________________________________________________________________________________________ Contact Phone #1 ________________________________ Contact Phone #2 ___________________________ Contact Fax # ___________________________________ Warehouse Contact Name __________________________________________ Title or Position ______________________________ Email ________________________________________________________________________________________ Contact Phone #1 ________________________________ Contact Phone #2 ___________________________ Contact Fax # ___________________________________ Customer Service Contact Name __________________________________________ Title or Position ______________________________ Email ________________________________________________________________________________________ Contact Phone #1 ________________________________ Contact Phone #2 ___________________________ Contact Fax # ___________________________________

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1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com PureCare New Customer Account – Financial Information To be Completed by the New Customer Section A: Company Information

Application Date _____/______/______

Legal Company Name _______________________________________________________________________________ D.B.A. ________________________________________________________________________________________________ Bill to Address __________________________________ City/State/Zip ___________________________________________ Ship to Address __________________________________ City/State/Zip _________________________________________

Section B: Credit Information Ownership (check one) …… Corporation …… Limited Liability Company

…… Partnership

…… Individual

Federal ID# _________________________________ Dun & Bradstreet # _______________________________ Years in Business ________________________________________________________________________________ Owner; Officer or Principal ________________________________ Title or Position ______________________ Owner; Officer or Principal ________________________________ Title or Position ______________________ Owner; Officer or Principal ________________________________ Title or Position ______________________ Bank Reference #1 Bank Name _______________________________________________ Bank Address, City, State _______________________________________________________________ Bank Account # _________________________________ Bank Phone # ___________________________ Bank Officer _____________________________________ Bank Fax # ______________________________ Bank Officer Email _________________________________________________________________________ Bank Reference #2 (optional) Bank Name _______________________________________________ Bank Address, City, State _______________________________________________________________ Bank Account # _________________________________ Bank Phone # ___________________________ Bank Officer _____________________________________ Bank Fax # ______________________________ Bank Officer Email _________________________________________________________________________ (continued on Page 6) Page 5 of 7

1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com Section C: Credit/Trade References Reference #1 Company Name ___________________________________________ Your Account # ____________________ Company Address, City, State __________________________________________________________________ Credit Mgr/Contact _________________________________ Email _____________________________________ Company Phone # _____________________________ Company Fax # _______________________________ Reference #2 Company Name ___________________________________________ Your Account # ____________________ Company Address, City, State __________________________________________________________________ Credit Mgr/Contact _________________________________ Email _____________________________________ Company Phone # _____________________________ Company Fax # _______________________________ Reference #3 Company Name ___________________________________________ Your Account # ____________________ Company Address, City, State __________________________________________________________________ Credit Mgr/Contact _________________________________ Email _____________________________________ Company Phone # _____________________________ Company Fax # _______________________________

Section D: Terms and Certification All payment terms are prepay with credit card until other terms are determined through credit check process and have been approved by PureCare.

Payment Method after Terms are established: Please pay via company check or electronic funds transfer.

Disputes to invoiced amounts should be reported to accounting@purecare.com within seven (7) days.

Certification: We, the undersigned, serving as representative of the company indicated in Section A of this document on the date of this application, agree to pay PureCare within our approved terms. We, the undersigned, serving as representative of the company indicated in Section A of this document on the date of this application, further agree to pay a Finance Charge of 18% per annum (1.5% per month) on all past due balances. Signature below certified that all information provided on this application form is true and correct. Completion of Section A authorizes the bank/credit/trade references listed in Sections B and C of this document to release required information to Fabrictech 2000, LLC. Sales Tax Status: Fabrictech 2000, LLC is required to charge sales tax. If you are exempt, please attach a current copy of your exemption certificate or resale certificate.

Signature (required) ___________________________________ Title or Position __________________________________ Print Name ______________________________________________ Application Date _____________________________

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1402 S 40th Ave Phoenix, AZ 85009 Toll Free: 800.758.8563 Fax: 602.596.4281 www.purecare.com PureCare Customer Account – Credit Card Authorization Please complete this document to have a credit card charged until credit terms are established with PureCare.

Customer Information Legal Company Name __________________________________________________________________________________ D.B.A. ___________________________________________________________________________________________________ Bill to Address ____________________________________ City/State/Zip _________________________________________

Credit Card Billing Information Person Authorizing Credit Card charges to be charged by PureCare Name __________________________________________ Title or Position __________________________________________ Email ____________________________________________________________________________________________________ Phone # _________________________________________________________________________________________________

Credit Card Type (Choose 1) …… Visa

…… Master Card

…… American Express

…… Discover

Issuing Bank Name (if applicable) ________________________________________________________________ Card Number ___________________________________________________________________________________ Expiration Date _______________________________________ CCV# ____________________________________ Billing Address ___________________________________ City/State/Zip __________________________________ Authorization Authorized Employee agrees that all information provided is accurate and complete. Authorized Employee also agrees that all orders may be charged immediately prior to shipping. Changes to this card should be reported to accounting@purecare.com immediately to prevent delay in order processing.

Certification The undersigned is the duly authorized representative of the above stated company

Signature

_________

Date _______________________________________

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