Southwest Country
Wholesale Submission Form

With us you are protected, all your business, personal and credit information is kept completely secure.

In order to protect the retail market and our accounts, all wholesale buyer prospects are required to fill out this form.
Depending on the items to be purchased the minimum opening order can be from $250.00 to $1,250.00 plus shipping. Subsequent orders may also have a minimum. All orders are FOB., the manufacturer headquarters.

Business Information.

Contact Name:
Business Name:
Resale Number:
E-mail Address:
Address:
City:
State / Province:
Zip / Postal Code:
Country:
Business Phone Number:
Fax Number:

Business Reference Accounts:

Supplier's Account # 1

Name:
Account #:
Phone:

Supplier's Account # 2

Supplier's Name:
Account #:
Supplier's Phone:

Supplier's Account # 3

Supplier's Name:
Account #:
Supplier's Phone:

Bank Information:

Bank Name:
Business Account #:
Bank's Phone Number:

Merchandise Information:

Item title and quantity to be purchased:
Please write a clear description and the items URL/reference number from the address bar of your browser.

If you are paying with a credit card.

Credit Card:	VISA MasterCard American Express Discover Diners Club JBL
Credit Card #:
Expiration Date:

Please do not hit the submit button twice, the computer will pause momentarily while processing your request.

CLICK HERE FOR OUR SECURE ONLINE ORDER FORM.

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