Credit Request

WORLDWIDE GEMS LTD.

1. Rough Amethyst

2. Preform

3. Partially Cut

4. Finished Amethyst

CREDIT INFORMATION REQUEST FORM

PLEASE FILL IN THE INFORMATION BELOW SO THAT WE CAN VERIFY YOUR CREDIT STANDING. BY PROVIDING THIS DATA YOU AGREE THAT WE MAY CONTACT THE REFERENCES PROVIDED. WHEN YOU HAVE COMPLETED BOTH SECTIONS CLICK ON THE SUBMIT BUTTON TO SEND.

* Name:

Title:

Organization:

* Street Address:

Address (cont.):

* City:

State/Province:

* Zip/Postal Code:

* Country:

* Phone Number:

FAX:

* E-mail:

URL:

Please provide 3 trade industry credit references we may contact to obtain a credit rating for you. At least one should be either a diamond or coloured stone supplier. All references should be jewellery trade related please.

Reference #1
* Name:
* Phone Number:
Fax Number:

E-mail:
* How long have you had an account with them?
* What name is the account under?

Reference #2
* Name:
* Phone Number:
Fax Number:

E-mail:
* How long have you had an account with them?
* What name is the account under?

Reference #3
* Name:
* Phone Number:
Fax Number:

E-mail:
* How long have you had an account with them?
* What name is the account under?

* Required Information
Thank you for your time and patience. If you have incomplete information please email us at info@worldwidegems.co.nz. We will in most cases contact you within 48 hours. If you don`t hear from us please contact us since the request may not have been received due to web server/e-mail issues.

Reference #1 * Name:	* Phone Number: Fax Number: E-mail:	* How long have you had an account with them? * What name is the account under?
Reference #2 * Name:	* Phone Number: Fax Number: E-mail:	* How long have you had an account with them? * What name is the account under?
Reference #3 * Name:	* Phone Number: Fax Number: E-mail:	* How long have you had an account with them? * What name is the account under?

* Name:
Title:
Organization:
* Street Address:
Address (cont.):
* City:
State/Province:
* Zip/Postal Code:
* Country:
* Phone Number:
FAX:
* E-mail:
URL:

CREDIT INFORMATION REQUEST FORM

Copyright � 2008 Worldwide Gems Ltd. All rights reserved. Revised:

Copyright � 2008 Worldwide Gems Ltd. All rights reserved.
Revised: