New Wholesaler Application

New Wholesale Customer Application

Thank you for choosing Eclipse Wholesale Inc. as your premiere wholesaler for your Wholesale needs!
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#*
Wholesale License#*
Tobacco License#*
Resale 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*

Name*

First NameLast Name
Business Name*
Phone Number*
Please enter a valid phone number.
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 Resale Tax Certificate (Tax Exempt Form)
- State Tobacco License
- State Wholesale License
File Upload*

Cancelof
I, the purchaser named above, claim the right to make a non-taxable purchase (for resale of the taxable items described below) from:
Eclipse Wholesale Inc.
2509 Lovi Rd, Building 3
Freedom, PA 15042

The taxable items described above will be resold, rented, or leased by me within the geographical limits of the United States of America, its territories and possessions in their present form or attached to other taxable items to be sold.

I understand that if I make any use of the items other than retention, demonstration or display while holding them for sale, lease or rental, I must pay sales tax on the items at the time of use based upon either the purchase price or the fair market rental value for the period used.

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.
I understand, that as the purchaser of goods, I am required to report all purchases and sales weekly to MSA on time and accurately.
Name of Person Signing*

First NameLast Name
Title*
Signature

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All new accounts terms are set up as a payment on a prepay basis prior to shipment,unless contract agreement states otherwise.

We accept payments by check, wire transfer and/or ACH.
Should be Empty:

New Wholesale Customer Application

Accounts Payable

Owner Information

DISCLOSURE