YOUR COMPANY INFORMATION

Legal Business Name

DBA Name

Address

Street Address

City

State

Country

Postal Code

Federal Tax ID (EIN)

Years in Business

Type of Business

Company Phone

Company Email

BILLING / AP INFORMATION

AP Contact Name

AP Email

AP Phone

Purchase Orders Required

Yes

DISTRIBUTOR QUALIFICATION

Number of Active Buyers

Primary Distribution Territory

CREDIT SELECTION

Credit Terms Selection

BANK INFORMATION

Bank Name

Bank Account Number

Bank Contact Name

Bank Contact Information

TRADE REFERENCES

Trade Reference 1 Company Name

Trade Reference 1 Phone

Trade Reference 2 Company Name

Trade Reference 2 Phone

CREDIT DISCLOSURES

Tax Lien or Civil Suit (Last 6 Years)

Yes

Bankruptcy Ever Filed

Yes

Guarantor of Other Debts

Yes

PERSONAL GUARANTY

Guarantor Full Legal Name

Guarantor SSN

Guarantor Signature

Clear

Guaranty Date

AUTHORIZED SIGNER

Authorized Signer Full Name

Authorized Signer Title

Authorized Signer Signature

Clear

Authorized Signature Date

I agree to the terms above