Company Name:
Telephone:

Bill to Address
Street/PO Box:
City: State: Zip:

Is Your Business
Individually Owned Partnership Corporation

Is Your Business a
Division or Subsidiary? N/A
If so, Parent:

Type of Business
Wholesaler Treater Export Other

Name of Buyer for
Lumber Purchases:
Plywood Purchases:
Present Ownership: Years

Names and Titles of Principals
Principal #1:
Title:
Principal #2:
Title:

Current Balance Sheet
Will be Mailed Will be faxed to 601-264-3334
Estimated Annual Sales Volume: $
Primary Material Supplier:
Primary Material Supplier Phone:
Bank:
Bank Telephone:
Bank Officer's Name:

Please List Four Trade References
Reference #1: Ref. #1 Phone:
Reference #2: Ref. #2 Phone:
Reference #3: Ref. #3 Phone:
Reference #4: Ref. #4 Phone:

I, (We) represent, warrant, and confirm that all statements made by me, (us) in this credit statement are correct and have been made by me, (us) for the purpose of inducing the seller to extend this credit, and knowing that they will rely thereon. Attorneys fees of fifteen percent (15%) will be assessed as well as other costs incurred for collection.  Terms 1% 10, AD Net 11.

I understand and accept these terms.
My Name:
My Title:
My Email Address: