YOUR COMPANY INFORMATION
Legal Business Name
DBA Name
Address
Street Address
City
State
Country
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
No
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
No
Bankruptcy Ever Filed
Yes
No
Guarantor of Other Debts
Yes
No
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
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