Wholesale Inquiries

New Account Required Information
Please print form and fill out the required information (completely) and include all requested information before submitting this sheet via fax or mail.  It is very important that our New Accounts Department receive the following information as soon as possible in an effort to expedite the order process. Thank You!
STORE INFORMATION
Full Legal Business Name: DBA or AKA: (Store Name)
Store Phone Number: Store Fax Number:
Store Street Address: (cannot be a P.O. Box) City: State: Zip:
Billing Address: (if different from above) City: State: Zip:
Buyers Name: Buyers e-mail Address:
Type of Merchandise Carried in Store: Website:
BUSINESS INFORMATION
Person to contact Regading the Account e-mail address:
Parent Company (if different from above) Parent Compnay Phone Number
Parent Company Address: City: State: Zip:
Federal Tax ID Number (required) In Busines Since: Re-Sale Number (must attach copy) State:
Legal Structure: Do you operate your business from your home?
□ Corporation  □ LLC  □ Partnership  □ Sole Proprietor Are you a Franchise?
Owner/Partner’s/Corp Officers Name: Social Security Number:
BANKING INFORMATION
Financial Institution: Contact Person:
Branch/Location: Phone Number: Account Number:
CREDIT/TRADE REFERENCES
Name City/State: Phone:
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REQUESTED SHIPMENT TERMS CREDIT CARD PAYMENT INFORMATION
 □ Prepayment  □ COD  □ Account

 (if

 approved) Name on Credit Card:
□ Prepayment Credit Card (complete card information)
SIGNATURE Credit Card Number:
Expiration Date:(mm/yy) Billing Zip Code:
Please sign and print Name & Title Date