Indera Mills Company P.O. Box 309, Yadkinville, N.C. 27055   (336) 679-4440   Fax (336) 679-4475

Business Name /DBA Main Email
Corporate Name Telephone
Bill To Address Ship To Address
(If needed attach additional
 addresses at bottom of page.)
Account Payable Telephone Number Accounts Receivable Telephone Number
Accounts Payable Fax Accounts Payable Email
Accounts Payable Contact Is Purchase Order Required
                            Number of Years in Business
Federal Tax ID Number (for Corporations)
Owners, Partners or Corporate Officers
Name/Title Home Address Telephone Number Social Security Number

Bank Name Officer
Bank Address Account Number
    Telephone Number
Trade References (minimum of 4 required - attach additional at bottom of this page if needed)
Account Name Account Number  Telephone Number
Address   Fax Number
Account Name Account Number Telephone Number
Address   Fax Number
Account Name Account Number Telephone Number
Address   Fax Number
Account Name Account Number Telephone Number
Address   Fax Number
Account Name Account Number Telephone Number
Address   Fax Number
If you wish, orders may be shipped C.O.D or via Credit Card, to your authorized locations until verification of credit has been completed.  No shipment can be made, however, until this authorized dealer application has been signed and returned to our Credit Department.
Annual Sales
Primary Product Lines
Credit Limit you are Requesting
Opening Order Amount (minimum $500)

Financial Statements Attached
 (Upload at bottom of page)
Will be forwarded on (date)

We hereby apply for the extension of credit by your company.  The following is submitted as a basis for your consideration. 
All information is warranted to be true and accurate.
Business Name /DBA    
Corporate Name Telephone
Bill to Address
Ship to Address

Terms:    All orders are subject to credit approval.  Once the Dealer's credit has been approved, payment terms will be 
Net 30 Days from Date of Invoice or as agreed.

Shipments are F.O.B Yadkinville, N.C.; shipping charges will be listed separately on invoices.  Payment terms will be Net 30 days from date of FINANCE.

Shipments are the sole responsibility of the customer.  Liability rests with the Dealer if the shipment is refused.  Freight plus a 20% repackaging / restocking charge will be assessed on refused shipments.  This includes refused back orders.  It is the Dealer's responsibility to cancel back orders.

Authorizations may be requested for the return of items shipped in error.  Contact Customer Service for a Return Authorization Number.  Items returned without authorization or which do not appear on our current price sheet will not have credit value.  If an authorization is issued for reasons other than a Indera Mills' error, a 20% repackaging/restocking fee will be assessed.  Refused C.O.D orders are subject to a 25% repacking / restocking fee.  Freight will be paid by the Dealer. ALL RETURNS UNLESS OTHERWISE STATED ARE TO BE RETURNED TO:
Indera Mills Company, 350 West Maple Street, Yadkinville, N.C. 27055

No claim/chargeback, action, or demand may be brought by the Dealer more than one year after date of invoice.  The Dealer will pay all costs, including reasonable attorney fees and costs and court costs, incurred in any collection proceeding that was initiated as a result of the Dealers default.

I hereby authorize the person or firm to whom this application is made, any credit bureau, or other investigative agency employed by such a or entity, to investigate the references herein listed or statements or other data obtained from me or from any other person pertaining to my person credit and financial responsibility.
Company Name Indera Mills Company Dealer Company  
By (Signature Required)
By (Signature Required)




You can upload additional shipping addresses, trade references, and financial statements here if needed.
Please be sure that any files that you plan to upload include your company name and description of what the file inludes.
Example: inderamillsfinancialstatements.doc