Please fill in the necessary information, print out the form, sign it and either fax or e-mail it as an attachment to The Mat King:

Name: _____________________

Company Name: _____________________________

Address: ___________________________________

__________________________________________

City: ___________________ State: ________ Zip Code: __________

Phone Number: __________________

Fax Number: ____________________

E-Mail address: ________________________.

I ________________________ agree to indemnify and hold harmless Jandru Mats, Inc. d/b/a The Mat King and any and all of its officers, employees and agents or sources of product from any and all claims of whatsoever nature and kind including, without limiting the generality thereto, injury to persons, damage to property and claims for economic loss, arising out of the construction, installation, quality of goods supplied hereunder, or from anything undertaken or done in carrying out our contract.

X _______________________________

Print Name: ______________________

Position with Company: _____________________

Date: _____/ _____/ _____

               

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THE MAT KING
1600 Old Country Road; Suite 207
Plainview, NY 11803 USA

Phone: 516-501-0744
Fax: 516-501-0753
Phone: 800-442-6544
Fax: 800-Mats-Fax (628-7329)