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Customer Application
Company Name:   
Billing Address:    
City: , State:    Zip Code:
Shipping Address:
City: , State:    Zip Code:
Purchasing Accounts Payable
Contact: Contact:
Phone:--  ext:
Phone:--  ext:
Fax:-- Fax:--
E-Mail: E-Mail:
Type of Company
Purchase order required:
Statement required:
Tax status: if tax exempt please fax your certificate to 501-568-0203
Invoicing Method:

Trade References
Company Name:  
Contact:             
Phone:--  ext:       Account #:
Fax:--
Company Name:  
Contact:             
Phone:--  ext:       Account #:
Fax:--

Banking Information
Bank Name:        
Contact:             
Phone:--  ext:       Account #:
Additional Comments:

By submitting you authorize Arkansas Bag & Equipment Co. to electronically check credit worthiness.