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 require to fill out this form. Depending on the item 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., our headquarters in Encino CA.

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:

When you press SUBMIT, the computer pauses as it processes your order. Please do not hit the submit button twice, it is normal for the computer to pause while processing your order.

You can also use this form to include your self to our mailing list.

To go back to where you were before ordering click on the back arrow / bottom of your browser or hit the back space key of your keyboard.

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For More quality products click on the following links.

Thank you for your purchase. We ship all over the world.

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