New Customer Form

PO Box 609, Magnolia, AR 71754-0609
629 West Main, Magnolia, AR 71753-3594
Voice: (870)234-7399 or (800)365-5864
Fax: (800)234-5180
Email: [email protected]

Company Name:*

Type of Company:*

Propietorship

Corporation

Partnership

Billing Address:*

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip Code

E-mail:*

Phone:*

Area Code

Phone Number

Fax:

Area Code

Phone Number

Owners Name:

First

Last

State Sales Tax I.D. Number:*

Briefly describe the nature of your business:*

List your 3 major suppliers of merchandise:*

List 3 Credit References:*