SCRAP  PLASTIC/PAPER  PAYMENT REQUEST  FORM – Fax to 772-781-1393

 

Purchase Order Reference: _____________ 

Must Complete 1 (ONE) payment request per Container shipped

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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: ABA #_____________ ) Account # ______________________

 

I, ____________________, certify that the above information is true and correct and accordingly request payment of $_______________ for same.

 

 

________________                                       ___/____/201_

Signed                                                                     Date