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Personal Details

Title:

First Name:

Last Name:

E-Mail Address:

Website:

User Name:

Company Name:

Address and Contact Details

Address:

Address2:

City:

Country:

State:

Zip Code:

Phone:

Fax:

Wholesale Information

Federal Tax ID:

Fax us a copy of the Fed. Tax ID at 516-576-1313

Licence ID/SS #:

Type of Organization:

Trade Styles:

Type of Business:

Jobber/Wholesaler
Retailer
Exporter

Year Started:

State of Incorporation:

Duns Number:

Bank Information

Name of Bank:

Contact/Phone Number:

Date Account Relationship Established:

Bank Line:

Outstanding loan:

Collateral:

Checking Account Numbers:

Other Information

Corporate Officers:

Accounting Firm:

Address of Firm:

Accountant’s Name:

Affiliated Companies (including addresses):

Company 1:

Company 2:

Company 3:

Names of principals:

Name and %Ownership:

Home Address and Telephone Number:

(1):

(2):

(3):

Trade References (Top Five Suppliers):

Supplier:

Full Address:

Contact:

Telehone Number:

(1):

(2):

(3):

(4):

(5):

Statements Prepared:

Monthly
Quarterly
Annually

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