Picky Bars - Account Application

Company Name*
Contact Name*

First NameLast Name
Contact Position*
Store Phone Number*

Area CodePhone Number
E-mail*
Website*
No Online Sales*

I understand that I cannot sell Picky Bars online without prior approval.
How Did You Hear About Us?
Sales rep, magazine article, online, etc.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Buyer Name*

First NameLast Name
Buyer Number*

Area CodePhone Number
Finance Name*

First NameLast Name
Finance Number*

Area CodePhone Number
Retail Tax ID#*
Payment Method*

Credit CardTerms (Opening order will be placed on a Credit Card)
* Please note that Picky Bars will contact you for Credit Card information prior to the first shipment!
Signature*
Date*
Should be Empty: