Retailer Account Set-up Application

Retailer Application

ACCOUNT SET-UP FORM
Thank you for your interest to set up an account with our company.

Please complete this online form and click SUBMIT when done. All fields with asterisks are required, and this includes uploading Resellers certificate or State Tax ID# AND Federal Tax ID Number (EIN).

Please note that it will usually take 2-3 business days to review your application. We will contact you after your information has been validated.
BUSINESS INFORMATION
Complete Business Name*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
FAX Number
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Type of Company - Select One*
Reseller's Certificate or State Tax ID#*
Attach Reseller's Certificate or State Tax ID#*

Cancelof
Federal ID Number (EIN)*
Attach IRS EIN Certificate*

Cancelof
Number of Years In Business*
Type of Business*

Retail StorePractitionerPharmacySell on Own WebsiteOther
Please Provide Web Address*
Which of our company's products are you interested in?
OFFICERS & OWNERS
Number of Officers & Owners*
Name #1*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN or EIN Number*
Name #2*

First NameLast Name
Title*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN or EIN Number*
PERSONAL GUARANTEE
The undersigned declares that all information herein is true and correct. The undersigned Guarantor hereby also guarantees full and prompt payment and performance of all obligations owed to Prince of Peace, including payment of all charges. The guarantee is absolute and unconditional, and the liability of the Grantor is direct and may be enforced by Prince of Peace, without regard to the existence of other debtors of collateral.
Name*

First NameLast Name
Signature (please sign directly in the box below with your cursor)*

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Title*
Date*

MonthDayYear
Date
If you prefer to submit a hard copy instead of filling out the online form, kindly send or fax the completed documents to the following address:

Prince of Peace Ent., Inc.
Attn: Customer Service
Address: 751 N Canyons Parkway, Livermore, CA 94551
Tel: (925)292-3888
Fax: (925)371-1799

For any inquiries, please reach out to contact@popus.com, or call (800) 732-2328.
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Retailer Application

BUSINESS INFORMATION

OFFICERS & OWNERS

PERSONAL GUARANTEE