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:*
Billing Address:*
E-mail:*
Phone:*
-
Fax:
-
Owners Name:
State Sales Tax I.D. Number:*
Briefly describe the nature of your business:*
List your 3 major suppliers of merchandise:*
List 3 Credit References:*