Account Application Form
(Please fill out the form below, print and fax/mail it to us)
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.
