Wholesale Application Form

APPLICANT INFORMATION

DBA or Tradestyle

Company Name

Credit amount requested

DUNS Number

Tax ID

Buisness Address

First Name

Last name *

Company

Full address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

Email *

Phone

Fax

optional

Date Business Started

Vendor License Number

ASI Number

optional

PPAI Number

optional

Sage Number

optional

ACCOUNTS PAYABLE CONTACT INFORMATION

Type of buisness

Fax

A/P Phone

A/P Email

Mailing Address

A/P Manager First Name

A/P Manager Last Name *

Company

Full address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

BANK INFORMATION

Bank Name

Business Address

Bank Contact Person First Name

Bank Contact Person Last Name *

Company

Full address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

Email

Phone

Business/Trade References

Reference #1

Company Name

Account Number

Type Of Account

Address

Point Of Contact First Name

Point Of Contact Last Name *

Company

Full address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

FAX

Phone

Email

Reference #2

Company Name

Account Number

Type of account

Address

Point Of Contact First Name

Point Of Contact Last Name *

Company

Full address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

FAX

Phone

Email

Reference #3

Company Name

Account Number

Type Of Account

Address

Point Of Contact First Name

Point Of Contact Last Name *

Company

Full address *

Apartment, suite, etc. (optional)

City *

Country/Region *

Province/State/Region *

Postal code *

FAX

Phone

Email

Order products

Order Total (The sum of all the prices of all the items in the order, taxes and discounts included.)

Contact information

Shipping address

Billing address