Southern Polymer, Inc.

APPLICANT
- Company Name
  
  Bill to Address
  
  Ship to Address
  
  Phone No
  
  Invalid format.
  
  How long at this address?
  
  Fax No
  
  Invalid format.
  
  D & B No
  
  SIC Code No
  
  Website Address
  
  List Subsidiaries
  
  Accounts Payable Contact
  
  Telephone No.
  
  Invalid format.
  
  Extension
  
  Email
  
  Invalid format.
  
  Authorized to Purchase - Plant
  
  Office
  
  Operations, type and nature of business
  
  Date your organization was established
  
  Invalid format.
  
  Corporation Partnership L.P. Proprietorship
  
  State of incorporation (if applicable)
  
  Parent Company Name
  
  Address
  
  If publicly owned, check here
  
  Yes No
If privately owned, please complete the following
- Principal owners or stock holders:
- Name
  
  Ownership %
  
  Address
  
  Title
  
  Name
  
  Ownership %
  
  Address
  
  Title
  
  Name
  
  Ownership %
  
  Address
  
  Title
- Any change in ownership or senior management in the past year?
  
  Y N
  
  We expect our monthly credit requirements to be approximately
TRADE REFERENCES
- (Please list raw material/major suppliers) Fill out the complete company name, address, phone and fax numbers for each of your four (4) references.
- Name
  
  Please enter your email address.
  
  Telephone
  
  Invalid format.Please enter a password.
  
  Address
  
  Fax
  
  Invalid format.
  
  Name
  
  Telephone
  
  Invalid format.
  
  Address
  
  Fax
  
  Invalid format.
  
  Name
  
  Telephone
  
  Invalid format.
  
  Address
  
  Fax
  
  Invalid format.
  
  Name
  
  Telephone
  
  Invalid format.
  
  Address
  
  Fax
  
  Invalid format.
- If available, please attach a copy of your most recent Comparative Audited Balance Sheet, Income Statement, Cash Flow Statement and all related notes.
- Comparative Audited Balance Sheet *
  
  Income Statement *
  
  Cash Flow Statement *
  
  Related Notes *
Otherwise, you must provide the following infromation
- For year ending
  
  Annual Sales $
  
  Current Assets $
  
  Annual Expenses $
  
  Current Liabilities $
  
  Operating Profit $
  
  Long-term Debt $
  
  Number of Employees
  
  Equity $
  
  Source of Information
- The undersigned, on behalf of the Applicant, warrants that the information provided herein is true and correct, and is being provided for the purpose of obtaining credit. The undersigned also, on behalf of the Applicant, attests to the Applicant's financial responsibility, ability and willingness to pay any invoices submitted by Southern Plymer in accordance with net thirty (30) day payment terms. Southern Polymer is hereby authorized by Applicant to investigate the Trade and Banking References listed above.
- Company Name
  
  Please enter a value
  
  By
  
  Printed Name
  
  Title
  
  Date