Wholesale Application

Wholesale Application
To be considered for a wholesale account, please fill this application out. Thank you.

Company Name *

Billing Address *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Shipping Address (if different from Billing Address)

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Phone Number *

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Fax Number *

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Contact Person *

Email (this will be used to create your account) *

Name of Principle Owner or Officer *

Title *

How long have you been in business? *

Trade Reference #1

Company Name *

Reference Address #1 *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Reference Phone #1 *

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Reference Fax #1

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Trade Reference #2

Company Name *

Reference Address #2 *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Reference Phone #2 *

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Reference Fax#2

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Trade Reference #3

Company Name *

Reference Address #3 *

Street Address
Address Line 2
City	State / Province / Region
Postal / Zip Code	Country

Reference Phone #3 *

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Reference Fax #3

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I understand that my acceptance to these Terms & Conditions constitutes my original signature.

I understand that terms are "net 30 days", and a finance charge (18% APR) will apply to all past due accounts. I hereby authorize all references to release credit information regarding our company for application purposes. I also agree that should the account be sent to a collections company I am liable for, and will be charged for all costs incurred. I also certify, under penalty of perjury, that all information provided above is true and correct.

Do you agree with the terms and conditions? *

Yes, I agree.

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