New Retail Customer Application

New Retail Customer Application

Thank you for choosing Eclipse Wholesale Inc. as your premiere wholesaler for your retailer needs!
Sales Persons Name
Business Owner*

First NameLast Name
Business Name*
Business Phone*
E-mail*
example@example.com
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Type of Business*
Business Type
Others*
Date Business Opened*

MonthDayYear
Date
EIN#*
Tobacco License#*
Sales Tax License#*

Accounts Payable
Accounts Payable Contact*

First NameLast Name
Accounts Payable Phone*
Please enter a valid phone number.
Accounts Payable Email*
example@example.com
Owner Information
Name*

First NameLast Name
Driver License/ID#*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Social Security #*
Position/Title*

Business References

Please provide 2 business references.
Name*

First NameLast Name
Business Name*
Phone Number*
Please enter a valid phone number.
Name*

First NameLast Name
Business Name*
Phone Number*
Please enter a valid phone number.

Order Frequency*

WeeklyMonthlyPick-up
DISCLOSURE

All applications are reviewed, and processed within a (2) business day time frame. Failure to provide all necessary information and documents requested, may result in your application being delayed.
In order to process your application, we will need a copies of the following:
- Owner Drivers License
- State Sales Tax License
- State Tobacco License
- State Cigarette License
File Upload*

Cancelof
All new accounts terms are set up as a payment on delivery or ACH payment on delivery unless contract agreement states otherwise.

We accept payments by check, wire transfer and/or ACH.
- Any accounting disputes must be reported within 7 business days.
- Any delivery issues must be reported within 24 hours of the delivery being received.
The taxable items described above will be resold, rented, or leased by me within the geographical limits of the State of Pennsylvania.
I understand that it is a criminal offense to give a resale certificate to the seller for taxable items that I know, at the time of purchase, are purchased for use rather than for the purpose of resale, lease or rental, and depending on the amount of tax evaded, the offense may range from a Class C misdemeanor to a felony of the second degree.

By signing below, you are agreeing that you are an owner, officer, or an authorized person given the authority to submit this application and provide the documents required. You also understand that by signing this application, that it does not make you an active customer of Eclipse Wholesale Inc. until the verification process has been completed.
Name of Person Signing*

First NameLast Name
Title*
Signature

Powered by Jotform SignClear
Type a question
Should be Empty:

New Retail Customer Application

Accounts Payable

Owner Information

Business References

DISCLOSURE