Brochure

WAL-RICH CORPORATION SINCE 1950
CALL [phone] · www.wal-rich.com · FAX [phone]
252
PLEASE COMPLETE THIS CREDIT APPLICATION TO ESTABLISH AN ACCOUNT WITH
WAL-RICH CORPORATION. YOUR ASSISTANCE IN PROVIDING US WITH COMPLETE
INFORMATION WILL ENSURE THAT YOUR ORDER IS SHIPPED PROMPTLY.
THE WAL-RICH TEAM THANKS YOU FOR YOUR ORDER!
COMPANY NAME:
SHIPPING ADDRESS:
BILLING ADDRESS:
TRADE REFERENCES
YOUR COMPANY INFORMATION
PHONE: FAX:
PURCHASING CONTACT: A/P CONTACT:
CITY: STATE: ZIP:
EMAIL ADDRESS:
STATE RESALE #
COMPANY NAME:
ADDRESS:
CITY: ZIP:
PHONE: FAX:
STATE:
COMPANY NAME:
ADDRESS:
CITY:
ZIP:
PHONE: FAX:
STATE:
COMPANY NAME:
ADDRESS:
CITY: ZIP:
PHONE: FAX:
STATE:
BANK REFERENCE
SHIPPING INSTRUCTIONS
COMPANY NAME:
ADDRESS:
CITY: ZIP:
PHONE: FAX:
STATE:
BANK NAME:
ADDRESS:
CITY: ZIP:
PHONE: FAX:
STATE:
We certify that all the information on this form is correct, and fully understand Wal-Rich's credit terms. We agree to proper payment in
consideration of extended credit.
Authorized Signature (required) Title
Print Name Date
PENDING CREDIT APPROVAL, SHIP THIS ORDER
ASAP VIA CREDIT CARD
INSTRUCTIONS: