12630 S. Hamlin Court Alsip, Illinois 60803 Telephone (708) 396-8000 Fax (708) 388-9498

LEGAL NAME OF COMPANY MAILING ADDRESS:   Street     P.O. Box     City     State     Zip     Telephone     Fax   Pager     Mobile   HOW LONG IN BUSINESS   PLEASE CHECK ONE OF THE FOLLOWING: Corporation Limited Liability Company Partnership Individual   NAME(S) OF PRINCIPAL(S) 1. 2. NAME ADDRESS CITY/STATE   PRODUCT(S) TO BE PURCHASED REQUESTED CREDIT LINE PERSON TO CONTACT IF ANY QUESTIONS ON PAYMENT PURCHASE ORDERS REQUIRED Yes   No   BANK REFERENCE NAME OF BANK CITY & STATE PHONE NUMBER ACCOUNT # (BANK AUTHORIZATION MUST BE COMPLETED) Note: If you have a construction loan skip trade references and complete rest of form.   TRADE REFERENCES (Phone numbers MUST be included) Name City/State Telephone 1. 2. 3. 4. "I do hereby certify that the above information is true to the best of my knowledge, and will meet payment terms of net 30th prox. A finance charge of 1½% per month will be added to any amount over 30 days old." By checking this box you adhere to the statement above. NAME TITLE DATE   BANK AUTHORIZATION TO ESTABLISH CREDIT OR UPDATE CREDIT INFORMATION, WE AUTHORIZE (Name of Bank) TO PROVIDE ACCOUNT BALANCES, LOAN INFORMATION, AND OTHER PERTINENT INFORMATION TO M.R.LEE BUILDING MATERIAL, INC. AND TO CONTRACTORS ADJUSTMENT COMPANY COMPANY NAME PRINCIPAL NAME TITLE BANK ACCOUNT NUMBER * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * CONSTRUCTION LOANS ONLY NAME OF BANK OR TITLE COMPANY CITY/STATE CONTACT PERSON PHONE NUMBER ESCROW/LOAN NUMBER JOB ADDRESS OWNER OF PROPERTY PRODUCTS TO BE PURCHASED CONTRACT AMOUNT     HOME   |   Pricing   |   MSDS   |   Submittal Sheet   |   Related Mfg Links   |   California Joint Knife   M.R.Lee BUILDING MATERIALS INC. 12630 Hamlin Ct. - Alsip, IL 60803 Phone: 708/396-8000 - Fax: 708/388-9498 Send Email to: info@mrleeinc.com