Credit Card Application & Authorization

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Business Information (required)

Business Name

Business Email

Business Fax

Business Phone

Accounts Payable Contact

Buyer Contact Name

Mailing Address

City

State

Zip Code

Shipping Address

City

State

Zip Code

State Sales Tax Exemption # (required) In order for application to be finalized, a copy of your State Sales Tax Exemption Certificate must be sent to Farris Brothers either by fax to 601-264-3555 or to denise@farrisbrothers.com.

Applicant (required)

Home Address

Applicant Name

City

Social Security Number

State

Email Address

Zip Code

Cell Phone #

	The undersigned promises to pay for all purchases in accordance with the terms of sale on each invoice. If the undersigned's account becomes deliquent, the
undersigned agrees to pay all collection costs, charges and expenses (including reasonable attorney's fees) incurred in collecting the amount. The undersigned
also agrees to pay interest at the rate of 1 1/2% per month (18% Annually) on any amount delinquent over 30 days. I represent that the information on this form
is true and is given to induce Farris Brothers, Inc. to extend credit to the applicant. My company and I authorize Farris Brothers, Inc. to carry out an investigation
of credit as they see fit, including contacting the trade and bank references listed below and obtaining credit reports. I have read the terms and conditions above
and agree to them in full. An officer or owner of the above named corporation or of the above partnership or sole proprietorship must sign below. We impose
a surcharge of 2.75% on credit card transactions, which is not higher than our cost of acceptance.

PERSONAL GUARANTEE: By signing this application, I acknowledge that I personally guarantee the payments for all the items purchased on credit by this
company or corporation.

PURCHASE AGREEMENT: Any dispute or conflict involving the purchase, sale or use of any product sold or distributed by Farris Brothers,
Inc. shall be decided under the laws of Mississippi regardless of where it was manufactured.

I have read and agree to the Terms and Conditions above.

Invoice Delivery

Mailed Faxed E-Mailed

CREDIT CARD AUTHORIZATION

Primary Card Account

Name on Card

Card Number

Expiration Date

Card CVV

Billing Address

City

State

Zip Code

Secondary Card Account

Name on Card

Card Number

Expiration Date

Card CVV

Billing Address

City

State

Zip Code

I authorize Farris Brothers, Inc. to charge my invoices to the credit card(s) listed above:

This authorization is valid until I provide Farris Brothers, Inc. with a written cancellation.

Company Name:	*
Position:
Email / Login Name:	*
Desired Password:
Contact Name:
Phone:
Password Reminder Question:	*
Password Reminder Answer:	*

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Credit Card Application & Authorization