Credit Application

You may fill out this online form, or download an Acrobat PDF of the form to fax in.

Southland processes credit card orders immediatley, however most of our repeat customers choose to set up credit accounts. In order for us to process your credit application, please make sure you have already completled a new customer signup online, or over the telephone.

After we approve your application we will make the changes to your account so you may order online, or over the telephone with NET 30 terms. You should have a response from Southland within 24 hours (M-F 9:00am - 5:00pm) of submitting your application.

Legal Company Name:

Sales Contact:

Credit Amount Requested:

Same as Billing

Telephone:

Fax:

E-Mail:

Business Type:

Corporation Partnership Sole Proprietorship

Years in Business:

Number of Employees:

Premises:

Owned Leased

Dun & Bradstreet DUNS #:

Federal Tax ID #:

2.

Name:

Position:

Telephone:

3.

Name:

Position:

Telephone:

1.

Name:

Address:

Telephone:

Account Number:

2.

Name:

Address:

Telephone:

Account Number:

3.

Name:

Address:

Telephone:

Account Number:

1.

Company Name:

Address:

Contact:

Telephone:

Fax:

2.

Company Name:

Address:

Contact:

Telephone:

Fax:

3.

Company Name:

Address:

Contact:

Telephone:

Fax: