Online Application to Open a Retail Account

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Application for Credit Account

Printer-Friendly Version (PDF)

Please complete and click the submit button.

If you have any questions or need assistance, please call 1-800-933-8595, Ext. 16, or send us an email.

1. Company Name

2. D.B.A.

3. Resale #

4. Fed Tax ID #

5. Billing Address


Billing Street Address

City	State	Zip

Phone Number	Fax Number

5. Shipping Address


Shipping Street Address

City	State	Zip

Phone Number	Fax Number

6. Retail Location

Click box if same
as Shipping Address:


Retail Location Address

City	State	Zip

Phone Number	Fax Number

7. E-mail Address

8. Website

Do you sell online? Yes No

9. Store Description

10. Years in Business

11. Business is a:

	Sole Proprietorship
	Partnership
	Corporation

12. Company Owner

13. Authorized Buyers

14. Partners

15. Bank Information


Bank Name

City	State

Branch

16. Method of Payment

	Net 30
	Check
	Credit Card
	COD

17. Trade References (three required, i.e. companies with which your firm has reseller accounts):

Trade Reference #1








Account Number

Telephone	Fax

Trade Reference #2








Account Number

Telephone	Fax

Trade Reference #3








Account Number

Telephone	Fax

I accept these terms.

I/We hereby accept responsibility for invoices being paid within the stated terms. Should litigation be necessary to collect such invoices, court costs and attorneys' fees will be recovered by the prevailing party. The place of performance of this agreement and related orders shall be considered by the parties hereto to be New York, New York.

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