ASHLEY FURNITURE INDUSTRIES, INC. Confidential: For Credit Dept.

Use Only
ONE ASHLEY WAY – ARCADIA, WI 54612 Acct. #: ____________ Date Opened: _____________
Phone: 608-323-3377 Fax: 608-323-6512 D & B: ____________ Lyons: _____________
NEW ACCOUNT DATA SHEET Terms: ____________ C/L: _____________

Account Classification Code (Mandatory)

Please complete the following information on each new account. Orders for new accounts received without this sheet will be returned
to the Marketing Specialist for completion. Attachments are to include a sales tax exemption/resale certificate, if applicable, as well
as a current financial statement on the business.
Bill To:___________________________________________ Ship To:__________________________________________________

____________________________________________ __________________________________________________

____________________________________________ __________________________________________________

Telephone Number: ( )____________________________ Fax Number: ( )_________________________________________

Email Address: ____________________________________ Email Invoices are Acceptable Yes No

Ownership: Proprietorship Partnership Corporation Limited Liability Company

Principal Name/Title: ______________________________________________ S.S. # ______________________________________

Length of time in business: _______ years _______months. Is this business affiliated or part of another business who is now a
customer of Ashley Furniture Industries, Inc? If so, provide details: ____________________________________________________

TRADE REFERENCES:

Bank:______________________________________________ Branch Location: ______________________________________

Phone#: ________________________ Fax#: ________________________ Bank Acct #: ___________________________________

1. Supplier: _________________________________________________________________________________________________
Name Street Address
_________________________________________________________________________________________________________
City/State Zip Code Phone # Fax # Account #
2. Supplier: _________________________________________________________________________________________________
Name Street Address
_________________________________________________________________________________________________________
City/State Zip Code Phone # Fax # Account #
3. Supplier: _________________________________________________________________________________________________
Name Street Address
_________________________________________________________________________________________________________
City/State Zip Code Phone # Fax # Account #
4. Supplier: _________________________________________________________________________________________________
Name Street Address
_________________________________________________________________________________________________________
City/State Zip Code Phone # Fax # Account #

Ashley Case Goods Marketing Specialist_______________________ Stationary Upholstery Marketing Specialist________________

Motion Upholstery Marketing Specialist _____________________________

DELIVERY INSTRUCTIONS: 1. Must have appointment: Yes No

The above information is for the purpose of
obtaining credit and is warranted to be true.
I/we hereby authorize the firm to whom this
application is made to investigate the references
listed pertaining to my/our credit and financial
responsibility.
2. Closed on _______________ All Day _____________ ½ Day _______________
3. Receiving hours ________________________ to _________________________
4. Loading dock Yes No
5. After hours delivery accepted: Yes No
If accepted, number to call: ( ) ____________________________________
PAST DUE ACCOUNTS ARE SUBJECT TO 1 ½ % MONTHLY LATE PENALTY CHARGE.
Signed by:______________________________________Date: _______________
Title: ______________________________________________________________