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Business Information
Legal Business Name:*
dba (doing business as):
Name :*
E-mail: *
Username: *
Password : *
Repeat Password: *
Street Address :*
Contact:
Website URL:
Type of Business (choose one):
Corporation
LLC
Partnership
Sole Propietor
Shipping Address (if different from above)
Street Address:
Phone Number:
Key Company Personnel
Please state full names of company principals and titles
Name:
Title:
Contact:
Email :
Name:
Title:
Contact:
Email :
Key Company Contacts
* Account Payable Contact Information is required field
Accounts Payable - Name:
Title:
Contact:
Email:
Purchasing (Buyer) - Name:
Title:
Contact:
Billing Information
Email address(s) where invoice should be sent*:
Preferred Shipping Term (choose one)
Bill Freight
Use Own Freight Account
If using own freight account, please provide the information below
Freight Company's Name :
Freight bill-to-address :
Freight Company's Name:
Account Name:
Freight bill-to-address :
Email address(s) to where tracking information should be sent:
Email*:
Bank Reference
Instituation Name:
Address:
Contact Name:
Trade References (at least three)
* Please provide 3 references. If credit card payment term is preferred, trade references can be omitted and please fill out the credit card authorization form instead
Company Name:
Contact Name:
Address:
Phone No:
Fax:
Account Opened Since:
Company Name:
Contact Name:
Address:
Phone No:
Fax:
Account Opened Since:
Company Name:
Contact Name:
Address:
Phone No:
Fax:
Account Opened Since:
Credit Card Authorization
(Optional)
* If trade references were left blank please provide credit card information by either filling in the spaces below,or by completing the Credit Card Authorization form in PDF format.
Upload Credit Card Information :
Upload Reseller Certificate* :
Company Name:
Cardholder's Name :
Credit Card Billing Address :
Visa
Mastercard
American Express
Discover
Credit Card Number :
Email Address (To) where receipts should be sent* :
Terms and credit limits will be determined based on our credit review. Open account invoices not paid when due will be charged a past due handling fee of 1.5% (minimum of $30) per month until paid. Future orders may be placed on a Prepaid or COD basis until the account is current. Should collection or legal action be required to collect past due amounts, fees for such action will be added to your account. The undersigned authorizes inquiry as to credit information. We further acknowledge that credit privileges, if granted, may be withdrawn at any time. The undersigned agrees to all the above terms and conditions.
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