Wholesale Application

Company information

Company Name *

Phone # *

Sales & Use Tax Resale # *

Fax # *

Website *

Physical address *

Address line 2

City *

State/Province/Region *

Zip/Postal code *

Country *

Billing address (If Different from Physical)

City

State/Province/Region *

Zip/Postal code *

Country *

State of Incorporation *

Date of Incorporation *

Company Status *

Purchase Orders Required *

Purchaser Contact *

Purchaser Email *

Anticipated Monthly Volume *

Accounts Payable Contact *

Accounts Payable Email *

Customer Type

Brick & Mortar Storefront *

Normal Business Hours Open to Public *

Loading & Unloading Equipment *

Do you Currently Carry Similar Products *

Have a Yard Space to Safely & Effectively Display Product *

Please submit a copy of your State Sales and Use Tax Resale Certificate (Signed) *

Officers, Owners Or Partners

First name *

Last name *

Title

Email address *

First name

Last name

Title

Email address

First name

Last name

Title

Email address

Bank References

Bank Name *

Bank Contact *

Phone # *

City & State *

Bank Name

Bank Contact

Phone #

City & State

Trade References

Reference Name *

Reference Contact *

Phone # *

Fax # *

Reference Name *

Reference Contact *

Phone # *

Fax # *

Reference Name *

Reference Contact *

Phone # *

Fax # *

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