WHOLESALE CREDIT ACCOUNT APPLICATION

Instructions: Please print or type. Fill in all applicable spaces and complete by signing where indicated. If a corporation, the signature must be that of an officer. If a partnership, this application must be signed by all partners

* Indicates required field

Name of Company ^* :

Billing Address ^* :

Delivery/Orders Address ^* :

Phone ^* :

Fax:

Person (s) Authorized to Buy ^* :

Is a PO Number Needed:

Yes

Is Company Tax Exempt?

Yes

If yes, please submit PA Sales Tax Exempt Form

Type of Business ^* :

Date Company was founded ^* :

Type of Organization

PROPRIETORSHIP

PARTNERSHIP

CORPORATION

PROPRIETOR/PARTNER

Owner ^* :

Address ^* :

Address :

CORPORATION

List Officers:

BANK NAME ^* :

Phone ^* :

Officer or Department:

Accounts Payable Contact Name ^* :

Phone ^* :

Email ^* :

Please check if you would like your invoices, credits and statements sent by email.

Invoices: Email ^* :

Credits: Email:(recommended)

Statements: Email:(recommended)

Type of Account Requested

Charge

COD

Credit Card

Please upload your sales tax exemption certificate here (optional)

We have the ability to receive payment by ACH or Credit Card.
To get set up on either of these payment options please contact our Office (484-342-0470 tarabobs@verizon.net).

* Please sign the form electronically on the next page after submitting here.