This is an application to become a Buckley Rumford Store Dealer to sell screens, gas logs and other products related to Rumford fireplaces. If you are a masonry materials dealer and want to become a Superior Clay dealer and carry the Rumford components, clay chimney pots and other masonry products, click here. To become a Buckley Rumford Dealer, print out, complete form, and mail or fax to: Buckley Rumford Co. 1035 Monroe Street Port Townsend, WA 98368 360 385 9974 (fax 360 385 1624) buckley@rumford.com

Name of company_________________________________________________ Address_________________________________________________________ ________________________________________________________________ Phone______________________________FAX_________________________ Company is a Corporation______, Partnership_______, or Proprietorship_____ Tax ID number___________________ Number of years in business__________ Company officers________________________ _________________________ _______________________________________ _________________________ Bank name________________________ Officer's name __________________ Bank address_____________________________ Phone__________________ Bank account numbers_____________________ _________________________ Trade references: 1. _________________________________ ____________________________ 2. _________________________________ ____________________________ 3. _________________________________ ____________________________ Are there suits for debts owed or unsatisfied judgements against the company or has the company or any entity controlled by the company been declared bankrupt within the last ten years?_________ If yes, explain _________________________________________________________________ _________________________________________________________________ Authorized Signor_____________________________ Date__________________ Title___________________________ Office use only Approved_______________________ Limit __________________ Date ________ Not approved____________________ Reason_________________ Date ________

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