dirthappens.com     FAX ORDER     505-989-1761

 

 

 

 

New Account?  Include “New Account Application” with your fax order.

 

 

 

Bill to:

 

Name: ________________________ Company Name: _______________________

 

Address: __________________________________________________________

 

City: ______________________ State: ___________________ Zip: ____________

 

 

Ship to:

 

Name: ________________________ Company Name: _______________________

 

Address: __________________________________________________________

                   (physical address only – we cannot ship to a Post Office Box)

City: ______________________ State: ___________________ Zip: ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Method of payment:          Cash          Check          Bank Card

 

Bank Card Name: __________________ Card Number: ________________________

 

Expiration: ___________________ Signature: ______________________________

                                                                                                        (we must have a signature to process bank cards)

 

 

 

 

 

 

By:

 

Name of firm or Individual: ______________________________________________

 

Address: __________________City: _____________ State: ________ Zip: _______

 

Phone: ______________________ Fax: ___________________

 

Owner:

 

     Corporation          Partnership          LLC          Individual

 

Name(s) and Address(es) of Principals

 

1. _______________________________________________________________

________________________________________________ Phone: ___________

 

2. _______________________________________________________________

________________________________________________Phone: ___________

 

3. _______________________________________________________________

________________________________________________Phone: ___________

 

Finance:

 

Bank: ____________________________________________________________

 

Address: _________________________________________Phone: ____________

 

Bank: ____________________________________________________________

 

Address: _________________________________________Phone: ____________

 

References:

 

1. Name: ____________________ Phone: ________________________________

 

Address: __________________________________________________________

 

2. Name: ____________________ Phone: ________________________________

 

Address: __________________________________________________________

 

We certify that all the information on this form is correct.  We fully understand your credit terms and agree to the proper payment in consideration of extended credit.

 

Signed: ___________________________ Title: _____________ Date: __________