Resale #

Store Name / DBA

Street Address

City

State

Zip

Phone

FAX

Email

Authorized Buyers

Proprietor or Partner's Name

Accounts Payable Address

Accounts Payable City

Accounts Payable State

Accounts Payable Zip

Type of Business (main retail items)

Other brand carried:

At present location since:

Year Established

References:
In order to expedite your request for credit, please complete name, address, and phone number of your references.

Reference One:

Name

Terms Given

Account Number:

Street Address

City

State

Zip

Phone

FAX

Reference Two:

Name

Terms Given

Account Number:

Street Address

City

State

Zip

Phone

FAX

Reference Three:

Name

Terms Given

Account Number:

Street Address

City

State

Zip

Phone

FAX

Verification:
Please type the numbers/letters you see below to verify your application.