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New Customer Application:
Please select with of the following applies to you:
Wholesale Distributor
Retailer
Please select your SALES REPRESENTATIVE:
Omer Qadeer
Shwetah Mehra
None
Other
COMPANY INFORMATION
Legal Business Trade Name(applicant):
D/B/A:
Years at present location:
Is This a Residence?:
Yes
No
Address:
suite:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
Email Address:
BILLING INFORMATION
A/P Contact:
Phone:
Billing Address:
suite:
City:
State:
Zip Code:
Country:
Same as Above
SHIPPING INFORMATION
Shipping Contact(s):
Phone Number:
Shipping Address:
suite:
City:
State:
Zip:
Country:
Same as Above
Drop Ship Authorization:
Yes
No
Comments:
BUSINESS INFORMATION
Type of Business:
Corporation
LLC
LLP
Partnership
Proprietorship
Other
Date Incorporated:(mm/dd/yyyy)
State of Incorporation:
D&B Number:
Federal ID:
Do you Own or Rent?:
Own
Rent
TRADE REFERNCES
(Related industry purchases during the past 12 months)
Reference 1:
Business Name:
Address:
Contact Person:
Phone:
Account:
Reference 2:
Business Name
Address
Contact Person
Phone:
Account:
Reference 3:
Business Name:
Address:
Contact Person:
Phone:
Account:
PAYMENT:
PAYMENT TYPE:
(Please check the one that you would like to request):
Wire Transfer/ACH
COD (Certified Check/Money Order)
BANK REFERENCES 1
Bank Name:
Complete Address:
Account Number(s):
Years dealing with this bank:
Bank officer to Contact:
Phone (inc. area code):
Fax (inc. area code):
BANK REFERENCES 2
Bank Name:
Complete Address:
Account Number(s):
Years dealing with this bank:
Bank officer to Contact:
Phone (inc. area code):
Fax (inc. area code):
AUTHORIZED BUYERS
AUTHORIZED BUYER 1
Name:
Phone:
Email Address:
AUTHORIZED BUYER 2
Name:
Phone:
Email Address:
AUTHORIZED BUYER 3
Name:
Phone:
Email Address:
PRINCIPAL INFORMATION
Owner/Partner(s) Name:
Social Security:
Drivers License:
Address:
City:
State:
Zip Code:
Country:
Have any of the partners/owners/guarantor(s) of the company ever filed for bankruptcy:
Yes
No
(if Yes, please fill date filed and status fields.)
Date Filed:(mm/dd/yyyy)
Status:
Name of Share holders/partners:
1.
2.
3.
Applicant
Printed Name:
Title:
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