REQUEST NEW ACCOUNT

Account Name:  
Address:  
Addr 2:  
City:  
State:  
Zip Code:  
Phone Number:  
Fax Number:  
E-mail Address:  
Referred By:  

Billing Information
Bill To:  
Address:  
Addr 2:  
City:  
State:  
Zip Code:  

Shipping Information
Ship To:  
Address:  
Addr 2:  
City:  
State:  
Zip Code:  

Company Information
Main Title:  
In-Charge Name:  
Present Location For:   Years
Terms Requested:

Decorative Trade References
Ref 1 Name:  
Account #:   Phone:  
City, State Zip:  
Ref 2 Name:  
Account #:   Phone:  
City, State Zip:  
Ref 3 Name:  
Account #:   Phone:  
City, State Zip:  

Please Read
I hereby agree and warrant that all statements made on this application are true and correct. I also agree to pay in accordance with my approved credit terms with the understanding that there will be a service charge, not to exceed 1% - 1 1/2% per month (18% per year) on any past due balances. If the account is assigned for collection with an attorney or collection agency, I hereby agree to pay attorney fees, collection, and court cost incurred.

I Agree with the above.       I Disagree with the above.
Driver Lic. #:   State:  
Resale Certificate Permit #:  
Please send Me Your Sample Book: Yes No 
Type of Fabric Book:   
Type of Business:   
If Other:  
All Retail / Fabric Stocking Outlet will be entered on
"Outlet List" for Closeout Sales.