Wholesale Application
Date:_________________________________
Legal Name of Company/Corporation:_____________________________________________
Store Name/DBA Name (if different):______________________________________________
Business Owner:___________________________ Contact Person: _______________________
Billing Address:______________________________________________________________
(street)
______________________________ ___________________ __________________
(city) (state) (zip)
Business Phone:__________________________________ Fax:__________________________
E-Mail:___________________________________ Website: ____________________________
Federal EIN: _________________________ Sales Tax #: __________________ State: _______
Payment Preference: Visa: ____ MasterCard:____ AmEx____ Discover____ Check: ____ Money Order: ____ Paypal:______(Paypal Email Address:__________________________)
Credit Card Information:
Name (Exactly as it appears on card):
________________________________________________
Card Number:____________________________ Expiration:____ /____ CVV: __________
Signature authorizing card billing at time of shipment (required): _______________________________________
Type of Business:
Independent Retailer:_________
Small Chain (less than 5 stores): __________
Home Based Business: _____________
Internet: __________
Other: _____________ Please Explain: _____________________________________________
Legal Name of Company/Corporation:_____________________________________________
Store Name/DBA Name (if different):______________________________________________
Business Owner:___________________________ Contact Person: _______________________
Billing Address:______________________________________________________________
(street)
______________________________ ___________________ __________________
(city) (state) (zip)
Business Phone:__________________________________ Fax:__________________________
E-Mail:___________________________________ Website: ____________________________
Federal EIN: _________________________ Sales Tax #: __________________ State: _______
Payment Preference: Visa: ____ MasterCard:____ AmEx____ Discover____ Check: ____ Money Order: ____ Paypal:______(Paypal Email Address:__________________________)
Credit Card Information:
Name (Exactly as it appears on card):
________________________________________________
Card Number:____________________________ Expiration:____ /____ CVV: __________
Signature authorizing card billing at time of shipment (required): _______________________________________
Type of Business:
Independent Retailer:_________
Small Chain (less than 5 stores): __________
Home Based Business: _____________
Internet: __________
Other: _____________ Please Explain: _____________________________________________
