The Rumford Store
Dealer Credit Application

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)

Name of company_________________________________________________

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__________________


Office use only

Approved_______________________ Limit __________________ Date ________
Not approved____________________ Reason_________________ Date ________

Buckley Rumford Fireplaces
Copyright 1996 - 2009 Jim Buckley
All rights reserved.