[DISTRIBUTOR]

Distributor Online Application Form ( For New Account Only)

APPLICATION FOR CREDIT

Account Name / Company Name
Contact Person
Contact Email
Company Website:
Contact Person Title
Address
City
State / Zip
Telephone
Fax
Years in business
Annual Sales ($)
Employees numbers

Describe your business:

( e.g. what you do and what products you want to purchase from us etc...)

Type of ownership
Name(s) of Principal(s)
Sales Tax Exemption Status



( If Yes, please provide a copy and a number here)
Account Payable
A/P email
Bank Reference
- Bank Name
- Account Number
- Contact Officer
- Contact phone numer
Current NON-COMPETITIVE TRADE REFERENCES ( Need 3 of them )
Company Name
Contact Person
City / State
Tel:
Fax:
 
 
Company Name
Contact Person
City / State
Tel:
Fax:
 
 
Company Name
Contact Person
City / State
Tel:
Fax:
 
 
   
WE CERTIFY THAT ALL THE INFORMATION ON THIS FORM IS CORRECT. WE FULLY UNDERSTAND YOUR CREDIT TERMS AND AGREE TO THE PROPER PAYMENT IN CONSIDERATION OF EXTENED CREDIT.
Signed:
Title:
Date:
Please also email or fax your Resale Certificate to us in order to complete this application. Thank you.
   

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