SCRAP PLASTIC/PAPER PAYMENT REQUEST
Purchase Order Reference: _____________
Must Complete 1 (ONE) payment request per
Container shipped
==========================================================
Material Description: ______________________
Number of Bales: _______
Number of Gaylords: ________ @ _____ lbs each
Number of Pallets: ________ @ _______ lbs each
Van ID #: _______-__
Van Length: _______ feet
Seal Number ___________
Date Delivered to Port: ____/____/201_ (Month/Day/Year)
Booking Number Reference: __________________ Seaway
Bill # _______________________
Material Net Weight: __________ pounds
(Detailed Invoice Attached: Yes ____ No ____: if NO,
explain______________________________________)
(B/L or Seaway Bill Attached; Yes ____ No _____;if NO, explain
________________________)
(Weight Ticket Attached: Yes ____ No ____: if NO,
explain______________________________________)
(Minimum 4 Photos Attached: Yes ____ No ____: if NO,
explain______________________________________)
Price per pound: $ _____ (Attach detailed Manifest if
mixed load)
Total Load Value Payment Requested: $ ____________
Payee Name Requested: ________________
Payee Remittance Address: ________________________
________________________
City/State/Zip_______________________
Tel/Fax ________________________
If payment via W/T:
(If
Foreign Bank: Intermediary Bank Name:__________________Address:______________________
SWIFT#:________
Account Number: _______________________)
Payee
Bank Name : ____________________________
SWIFT #: _____________________
Branch
Address:_________________________ Phone #_______________
(If
USA:
I, ____________________, certify that the above
information is true and correct and accordingly request payment of
$_______________ for same.
________________
___/____/201_
Signed Date