Southland Industrial Supply, Inc.

Customer Information and Credit Application Form

 

Company Name:        ______________________________________________________

Mailing Address:       ______________________________________________________

                                    ______________________________________________________

Shipping Address:    ______________________________________________________

            ______________________________________________________

Phone #  ______________________________     Fax # ___________________________

Email:    ________________________________________________________________

Purchasing Contact _____________________________________    Ext: ____________

Accounts Payable Contact _______________________________    Ext: ______________

Federal Tax ID #  _____________________________County______________________

Sales Tax #  _______________________________     State of Exemption ____________

Credit References:  (3 required)

Name: __________________________________________________________________

Address: ________________________________________________________________

Contact:  ________________________________________________________________

Phone #  ______________________________     Fax # ___________________________

Name: __________________________________________________________________

Address: ________________________________________________________________

Contact:  ________________________________________________________________

Phone #  ______________________________     Fax # ___________________________

Name: __________________________________________________________________

Address: ________________________________________________________________

Contact:  ________________________________________________________________

Phone #  ______________________________     Fax # ___________________________

 

Bank Name: _____________________________________________________________

Address:    ______________________________________________________________

Contact: _____________________________ Account #  _________________________ Phone #  ______________________________     Fax #   _________________________

 

Fax (770) 531-0781     or     Mail to   P.O. Box 1474,   Gainesville,    GA   30503