Customer Application Form

Personal Information

First Name *

Last Name *

Email *

Phone *

Business Information

Business Legal Name *

DBA (Doing Business As)

Street *

City *

State *

Zip *

Business Phone *

Fax

Purchasing Agent Name *

Business Email *

Shipping address is different than billing

Shipping Information

Name

Street

City

State

Zip

Phone

Payment & Business Details

Payment Terms *

ACH / Bank Draft Credit Card Cash Before Delivery

Business Type *

Corporation Partnership Sole Proprietorship Non-Profit

Premises

Own Rent

Date Business Started

Federal EIN *

DUNS #

ACH Authorization Form

Company Name *

Name of Bank *

Bank Routing / Transit # (9 digits)

We do not collect bank details online — a rep will set up ACH with you directly.

Bank Account #

We do not collect bank details online — a rep will set up ACH with you directly.

Bank Account Type *

Checking Savings

Authorization Type

One-Time Recurring

Amount

Invoice Numbers (comma-separated)

Print Name *

Position *

Credit Card Authorization Form

Company Name *

Name on Card *

Billing Address *

City *

State *

Zip *

Credit Card Type *

Visa MasterCard American Express Discover

Authorization Type

One-Time Recurring

Amount

Print Name *

Position *

Owners and Partners

Sales Tax Exemption

Our business is exempt from sales tax

Tax Exemption Number *

Reason for Exemption *

A representative will request your exemption certificate after reviewing your application.

Uniform Sales & Use Tax Exemption / Resale Certificate

Issued to Seller *

Address *

Name of Firm (Buyer) *

Street *

City *

State *

Zip *

Business Type

Wholesaler Retailer Manufacturer Seller (California) Lessor Other

Other (Specify)

General description of tangible property or taxable services to be purchased *

State Registration, Seller's Permit, or ID Number of Purchaser

Signature

Sign above using a mouse, finger or stylus. Signature captured.

Title *

Date

Authorization

I certify that the information provided is true and correct, and I am authorized to submit this application on behalf of the business named above. *

Print Name *

Position *

Signature *

Sign above using a mouse, finger or stylus. Signature captured.

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