Account Application Form
(Please fill out the form below, print and fax/mail it to us) PDF form (Right Click & Save As...)
Date: | |
Profile | |
Company Name | Number of Stores |
Tax ID/Resell # | Years in Business |
Full Contact Name | Position |
Phone | Fax |
Email | Website |
Billing Contact | Phone |
Bank Name | (not necessary for Pre-paid account) |
Bank Account | (not necessary for Pre-paid account) |
Bank Address | (not necessary for Pre-paid account) |
Bank Phone No. | Contact |
Billing Address | |
Number / Street | |
City, State, Zip | Country |
Shipping Address | |
Number / Street | |
City, State, Zip | Country |
Trade Reference | |
# 1 Company Name | Account # |
Phone | Fax |
Account Since High Credit | |
# 2 Company Name | Account # |
Phone | Fax |
Account Since High Credit | |
# 3 Company Name | Account # |
Phone | Fax |
Account Since High Credit | |
Payment Info | (If applying for Pre-paid Account) |
Credit Card # | Exp.Date mm/yyyy |
Name on Card | Billing Address Same Yes No |
Number / Street | |
City, State, Zip | Country |
Credits / Terms (For Official Use Only) | |
Credit Terms | Account # Balance |
Additional Notes | |
*All fields are required. Information will be kept confidential.