Please provide the following contact information:

Name
Title
Business Name
Postal Address
Address (cont.)
City
State
Zip/Postal Code
Email
Business:	Please describe your business.
Business Structure	Corporation, Partnership, Etc.
Number of Employees
Tax I.D. Number	If applicable.
Parent Company:	If applicable

           SHIP TO ADDRESS

Attention:
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code

           TRADE REFERENCES

Company Name
Contact Name
Telephone Number
Fax Number
Open Since
Company Name
Contact Name
Telephone Number
Fax Number
Open Since

         CONFIRMATION OF INFORMATION AND RELEASE OF AUTHORITY

        I hereby certify that the information on this application is correct.  Further I authorize trade references listed in this application to release the necessary information to establish a line of credit.

Name
Title

Enter the date of ... :

 

PLEASE ALLOW 3 DAYS FOR APPROVAL OF INITIAL CREDIT ORDER.

YOU MAY CHOOSE TO SPEED UP THE ORDER PROCESS BY ORDERING VIA CREDIT CARD THRU OUR SHOPPING CART OR BY CALLING US AT 205-428-8791 OR FAXING US AT 205-428-8780..

Opening credit account is subject to our approval.

Thank you.